Regional Citrate Anticoagulation Compared With Systemic Heparin and No Anticoagulation for Continuous Renal Replacement Therapy Circuit Patency in Critically Ill Adults: A Prospective Multicenter Observational Study

Background: The management of anticoagulation therapy during continuous renal replacement therapy (CRRT) presents a complex clinical challenge for patients who are critically ill. The selection of an optimal anticoagulation method for CRRT circuit maintenance remains a subject of ongoing critical care discussion because it needs to achieve both safety and effectiveness. The research evaluated the safety outcomes and treatment success rates between regional citrate anticoagulation (RCA) and systemic heparin anticoagulation (SHA) and anticoagulation-free CRRT for patients with acute kidney injury (AKI). Methods: A prospective comparative observational study was conducted over 24 months starting from April 2022 until March 2024. The study took place in two tertiary care intensive care units which operated in Egypt and Saudi Arabia during this multicenter study. The research included 150 adult patients with AKI who needed CRRT treatment which were distributed into three equal groups (n=50) based on their anticoagulation methods. Results: Primary endpoints focused on the incidence of circuit clotting and circuit life span (CLS). Secondary endpoints included bleeding complications, metabolic disturbances, and cost-effectiveness assessment. The study results showed that patients receiving regional citrate anticoagulation experienced fewer circuit clotting events (0.58±1.4) than patients who received heparin (0.86±1.4) or no anticoagulation (1.4±2.4) (p = 0.03). The circuit life span results indicated a positive trend for RCA at 26.4±20.5 hours but did not reach statistical significance when compared to heparin at 20.6±18.6 hours and no anticoagulation at 16±16.3 hours (p = 0.23). The heparin treatment group experienced all bleeding complications which affected 10% of patients while ionized hypocalcemia reported only within citrate group (p < 0.001). Conclusions: Despite both RCA and anticoagulation-free CRRT represent viable therapeutic options for patients at increased risk of bleeding, the use of regional citrate anticoagulation provides better circuit performance and lower costs than other methods while eliminating all bleeding risks.