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Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study.
Arnold, Frederic; Westermann, Lukas; Rieg, Siegbert; Neumann-Haefelin, Elke; Biever, Paul Marc; Walz, Gerd; Kalbhenn, Johannes; Tanriver, Yakup.
  • Arnold F; Department of Medicine IV: Nephrology and Primary Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Westermann L; Institute of Medical Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Rieg S; Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Neumann-Haefelin E; Department of Medicine IV: Nephrology and Primary Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Biever PM; Department of Medicine II: Division of Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Walz G; Department of Medicine IV: Nephrology and Primary Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Kalbhenn J; Department of Medicine III: Interdisciplinary Medical Intensive Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
  • Tanriver Y; Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany.
BMC Nephrol ; 21(1): 486, 2020 11 16.
Article in English | MEDLINE | ID: covidwho-926325
ABSTRACT

BACKGROUND:

Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).

METHODS:

Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.

RESULTS:

In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM ±5.6 h), in the citrate group 45.6 h (SEM ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM ±1.3 h), with argatroban 8.0 h (SEM ±0.9 h), and with LMWH 11.8 h (SEM ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.

CONCLUSIONS:

UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.
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Full text: Available Collection: International databases Database: MEDLINE Main subject: Pneumonia, Viral / Renal Replacement Therapy / Coronavirus Infections / Acute Kidney Injury / Betacoronavirus / Anticoagulants Type of study: Cohort study / Observational study / Prognostic study Limits: Adult / Aged / Female / Humans / Male / Middle aged Country/Region as subject: Europa Language: English Journal: BMC Nephrol Journal subject: Nephrology Year: 2020 Document Type: Article Affiliation country: S12882-020-02150-8

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Full text: Available Collection: International databases Database: MEDLINE Main subject: Pneumonia, Viral / Renal Replacement Therapy / Coronavirus Infections / Acute Kidney Injury / Betacoronavirus / Anticoagulants Type of study: Cohort study / Observational study / Prognostic study Limits: Adult / Aged / Female / Humans / Male / Middle aged Country/Region as subject: Europa Language: English Journal: BMC Nephrol Journal subject: Nephrology Year: 2020 Document Type: Article Affiliation country: S12882-020-02150-8