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1.
Crit Care ; 25(1): 299, 2021 08 19.
Article in English | MEDLINE | ID: covidwho-1367680

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) may predispose patients to thrombotic events. The best anticoagulation strategy for continuous renal replacement therapy (CRRT) in such patients is still under debate. The purpose of this study was to evaluate the impact that different anticoagulation protocols have on filter clotting risk. METHODS: This was a retrospective observational study comparing two different anticoagulation strategies (citrate only and citrate plus intravenous infusion of unfractionated heparin) in patients with acute kidney injury (AKI), associated or not with COVID-19 (COV + AKI and COV - AKI, respectively), who were submitted to CRRT. Filter clotting risks were compared among groups. RESULTS: Between January 2019 and July 2020, 238 patients were evaluated: 188 in the COV + AKI group and 50 in the COV - AKI group. Filter clotting during the first filter use occurred in 111 patients (46.6%). Heparin use conferred protection against filter clotting (HR = 0.37, 95% CI 0.25-0.55), resulting in longer filter survival. Bleeding events and the need for blood transfusion were similar between the citrate only and citrate plus unfractionated heparin strategies. In-hospital mortality was higher among the COV + AKI patients than among the COV - AKI patients, although it was similar between the COV + AKI patients who received heparin and those who did not. Filter clotting was more common in patients with D-dimer levels above the median (5990 ng/ml). In the multivariate analysis, heparin was associated with a lower risk of filter clotting (HR = 0.28, 95% CI 0.18-0.43), whereas an elevated D-dimer level and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was marginally associated with an increased risk of circuit clotting (HR = 2.15, 95% CI 0.99-4.68). CONCLUSIONS: In COV + AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with a low risk of complications.


Subject(s)
Acute Kidney Injury/drug therapy , Citric Acid/pharmacology , Continuous Renal Replacement Therapy/instrumentation , Heparin/pharmacology , Micropore Filters/standards , Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Adult , COVID-19/complications , COVID-19/epidemiology , Citric Acid/adverse effects , Citric Acid/therapeutic use , Cohort Studies , Continuous Renal Replacement Therapy/methods , Continuous Renal Replacement Therapy/statistics & numerical data , Female , Heparin/adverse effects , Heparin/therapeutic use , Humans , Kaplan-Meier Estimate , Male , Micropore Filters/statistics & numerical data , Middle Aged , Proportional Hazards Models , Retrospective Studies
2.
BMC Nephrol ; 22(1): 141, 2021 04 20.
Article in English | MEDLINE | ID: covidwho-1195914

ABSTRACT

BACKGROUND: Coronavirus Disease 2019 (COVID-19) infection has been associated with a hypercoagulable state with increased reports of thrombotic events. Acute kidney injury requiring dialysis is common in critically ill patients and circuit clotting compromises efficacy of treatment. This study aims to analyze the circuit life and circuit clotting during continuous kidney replacement therapy (CKRT) and intermittent hemodialysis in patients with and without COVID-19. METHODS: This is a single-center, retrospective cohort study in critically ill patients undergoing CKRT or intermittent hemodialysis between 1 February 2020 to 22 May 2020. Patients in the intensive care unit (ICU) with COVID-19 infection and contemporary controls who tested negative were included. Co-primary outcomes were functional circuit life for patients on CKRT and all circuit clotting events for patients on CKRT and/or intermittent hemodialysis. RESULTS: Seventy CKRT circuits and 32 intermittent hemodialysis sessions for 12 COVID-19 cases and 22 CKRT circuits and 18 intermittent hemodialysis sessions for 15 controls were analyzed. CKRT circuit clotting was more common in the COVID-19 group compared to the control group (64% vs 36%, p = 0.02), despite higher anticoagulation use in the COVID-19 group (41% vs 14%, p = 0.02). Functional CKRT circuit life was similar in COVID-19 patients and controls (median 11 vs 12 h, p = 0.69). On Cox regression analysis, circuit clotting was similar with hazard ratio (HR) 1.90 [95% confidence interval (CI): 0.89-4.04]; however, clotting was increased in COVID-19 patients after adjustment for anticoagulation use (HR: 3.31 [95% CI 1.49-7.33]). In patients with COVID-19, CKRT circuits with anticoagulation had a longer circuit life compared to CKRT circuits without anticoagulation (median 22 versus 7 h respectively, p <  0.001). Circuit clotting was similar in both groups undergoing intermittent hemodialysis. CONCLUSION: Dialysis clotting amongst COVID-19 patients is increased despite more anticoagulation use and the hazard for clotting is greater especially after adjusting for anticoagulation use. Circuit life was suboptimal in COVID-19 patients on circuits without anticoagulation and therefore routine use of anticoagulation amongst COVID-19 patients should be considered whenever possible.


Subject(s)
Acute Kidney Injury/therapy , COVID-19/therapy , Kidney Failure, Chronic/therapy , Kidneys, Artificial , Thrombosis/epidemiology , Acute Kidney Injury/etiology , Aged , Anticoagulants/therapeutic use , COVID-19/blood , COVID-19/complications , Case-Control Studies , Citric Acid/therapeutic use , Cohort Studies , Continuous Renal Replacement Therapy , Critical Illness , Female , Heparin/therapeutic use , Humans , Kidney Failure, Chronic/blood , Male , Middle Aged , Proportional Hazards Models , Renal Dialysis , Retrospective Studies , SARS-CoV-2 , Thrombosis/prevention & control
3.
J Crit Care ; 63: 22-25, 2021 06.
Article in English | MEDLINE | ID: covidwho-1062451

ABSTRACT

Acute Kidney Injury (AKI) is a frequent complication in critically ill patients with Coronavirus disease 2019 (COVID-19), and it has been associated with worse clinical outcomes, especially when Kidney Replacement Therapy (KRT) is required. A condition of hypercoagulability has been frequently reported in COVID-19 patients, and this very fact may complicate KRT management. Sustained Low Efficiency Dialysis (SLED) is a hybrid dialysis modality increasingly used in critically ill patients since it allows to maintain acceptable hemodynamic stability and to overcome the increased clotting risk of the extracorporeal circuit, especially when Regional Citrate Anticoagulation (RCA) protocols are applied. Notably, given the mainly diffusive mechanism of solute transport, SLED is associated with lower stress on both hemofilter and blood cells as compared to convective KRT modalities. Finally, RCA, as compared with heparin-based protocols, does not further increase the already high hemorrhagic risk of patients with AKI. Based on these premises, we performed a pilot study on the clinical management of critically ill patients with COVID-19 associated AKI who underwent SLED with a simplified RCA protocol. Low circuit clotting rates were observed, as well as adequate KRT duration was achieved in most cases, without any relevant metabolic complication nor worsening of hemodynamic status.


Subject(s)
Acute Kidney Injury/complications , Acute Kidney Injury/therapy , Anticoagulants/therapeutic use , COVID-19/complications , Citric Acid/therapeutic use , Critical Care/methods , Hybrid Renal Replacement Therapy/methods , SARS-CoV-2 , Blood Coagulation/drug effects , COVID-19/virology , Critical Illness , Heparin/therapeutic use , Humans , Male , Middle Aged , Pilot Projects , Treatment Outcome
5.
Adv Chronic Kidney Dis ; 27(5): 377-382, 2020 09.
Article in English | MEDLINE | ID: covidwho-796111

ABSTRACT

Acute kidney injury is a common complication in hospitalized patients with coronavirus disease 2019. Similar to acute kidney injury associated with other conditions such as sepsis and cardiac surgery, morbidity and mortality are much higher in patients with coronavirus disease 2019 who develop acute kidney injury, especially in the intensive care unit. Management of coronavirus disease 2019-associated acute kidney injury with kidney replacement therapy should follow existing recommendations regarding modality, dose, and timing of initiation. However, patients with coronavirus disease 2019 are very hypercoagulable, and close vigilance to anticoagulation strategies is necessary to prevent circuit clotting. During situations of acute surge, where demand for kidney replacement therapy outweighs supplies, conservative measures have to be implemented to safely delay kidney replacement therapy. A collaborative effort and careful planning is needed to conserve dialysis supplies, to ensure that treatment can be safely delivered to every patient who will benefit for kidney replacement therapy.


Subject(s)
Acute Kidney Injury/therapy , Anticoagulants/therapeutic use , COVID-19/therapy , Renal Replacement Therapy/methods , Thrombophilia/drug therapy , COVID-19/blood , Catheterization, Central Venous , Central Venous Catheters , Citric Acid/therapeutic use , Continuous Renal Replacement Therapy/methods , Hemodialysis Solutions/supply & distribution , Hemoperfusion/methods , Heparin/therapeutic use , Humans , Hybrid Renal Replacement Therapy/methods , Intermittent Renal Replacement Therapy/methods , Kidneys, Artificial/supply & distribution , Partial Thromboplastin Time , Renal Replacement Therapy/instrumentation , SARS-CoV-2 , Surge Capacity , Thrombophilia/blood
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