Citrate for continuous renal replacement therapy: safer, better and cheaper

Table 1 Comparison between three large randomized controlled trials comparing citrate to heparin anticoagulation for continuous venovenous hemofiltration

	CASH trial 2014 [1] (multicenter)			OLVG trial 2009 [2] (single center)			Hetzel trial 2011 [3] (multicenter)
Excluded (percentage of patients needing CRRT)	1,297/2,300 (94%)			170/385 (44%)			Not reported
Modality	Predilution CVVH			Postdilution CVVH			Predilution CVVH
Groups	Citrate	Heparin	P value	Citrate	LMWH	P value	Citrate	Heparin	P value
Number of included patients	66	73		97	103		87	83
Patient characteristics
Age	67 (36–87)	67 (23–85)		73 (64–79)	73 (67–79)		62 (SD 15)	65 (SD 12)
APACHE II	23 (11–53)	25 (6–43)		28 (27–30)	28 (27–29)		22 (SD 5.1)	22 (SD 5.5)
SOFA	10 (2–19)	11 (3–18)		11 (10–13)	11 (10–14)		10 (SD 3.0)	10 (SD 2.6)
Cause of acute kidney injury ^a
Septic	41%	37%		43%	49%		77%	75%
Ischemic (cardiogenic + hypovolemic)	50%	51%		80%	61%		Not reported
Safety
Adverse events needing discontinuation	5 (8%)	24 (33%)	<0.001	2 (2%)	19 (19%)	<0.001
Bleeding percentage ^b	3 (5%)	10 (14%)	0.09	0 (0%)	16 (16%)	<0.001	5 (5.7%)	12 (14.7%)	0.09
Citrate accumulation	4 (6%)			1 (1%)			1 (1%)
Efficacy
Circuit survival (hours) ^c	46 (2–138)	32 (1–72)	0.02	27 (13–47)	26 (15–43)	0.68	38 (SD 23)	26 (SD 19)	<0.001
Mortality
90-day	42%	42%	1.00	48%	63%	0.03
28-day	33%	35%	1.00				47%	41%

Values are median (25th to 75th percentile), means (standard deviation (SD)), number (%). ^aMore causes possible. ^bCriteria for bleeding differed between studies. ^cCalculated for the first filter in the CASH trial, and for all filters in the other two. APACHE, Acute Physiology and Chronic Health Evaluation; CASH, Citrate Anticoagulation Versus Systemic Heparinization; CRRT, continuous renal replacement therapy; CVVH, continuous venovenous hemofiltration; LMWH, low molecular weight heparin; OVLG, Onze Lieve Vrouwe Gasthuis; SOFA, Sequential Organ Failure Assessment.

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