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Kidney Week

Abstract: FR-OR57

Regional Citrate vs. Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy Among Critically Ill Patients with AKI: A Randomized Clinical Trial

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials


  • Zarbock, Alexander, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
  • Kuellmar, Mira, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany
  • Kindgen-milles, Detlef, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
  • Rosenberger, Peter, Universitatsklinikum Tubingen Medizinische Universitatsklinik, Tubingen, Baden-Württemberg, Germany
  • Bagshaw, Sean M., University of Alberta, Edmonton, Alberta, Canada
  • Kellum, John A., University of Pittsburgh, Pittsburgh, Pennsylvania, United States
  • Meersch, Melanie, Universitatsklinikum Munster, Munster, Nordrhein-Westfalen, Germany

Although current guidelines suggest the use of regional citrate anticoagulation as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses.


To determine the effect of anticoagulation strategies on filter lifespan and mortality, a parallel-group, randomized multicenter clinical trial was conducted in 26 centers across Germany between March 2016 and December 2018. Patients were randomized to receive either regional citrate (n=300) or systemic heparin anticoagulation (n=296) for continuous kidney replacement therapy.The two co-primary outcomes were filter lifespan and 90-day all-cause mortality. Secondary endpoints included bleeding complications and new infections.


Among 638 patients randomized, 596 (93.4%) patients (mean age, 67.5 (±12.4) years, 183 (30.7%) women) completed the trial.Median filter lifespan was 47h [IQR, 19-70h] in the regional citrate and 26h [IQR, 2-51h] in the systemic heparin group; absolute difference (AD), 15h [95%CI, 11h to 20h]; P<0.001). 90-day all-cause mortality was 51.2% (150/300) in the regional citrate and 53.6% (156/296) in the systemic heparin anticoagulation group (adjusted AD, -6.1% [95%CI, -12.6% to 0.4%]; adjusted HR, 0.79 [95%CI, 0.63 to 1.004]; adjusted P=0.054; unadjusted AD, -2.4% [95%CI, -10.5% to 5.8%]; unadjusted HR, 0.91 [95%CI, 0.72 to 1.13]; unadjusted P=0.38). Compared with systemic heparin anticoagulation, the regional citrate anticoagulation group had significantly fewer bleeding complications (15/300 [5.1%] vs. 49/296 [16.9%]; AD, -11.8% [95% CI, -16.8% to 6.8%]; P<0.001) and significantly more new infections (204/300 [68.0%] vs. 164/296 [55.4%]; AD, 12.6% [95% CI, 4.9% to 20.3%]; P=0.002).


Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter lifespan. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality.


  • Government Support - Non-U.S.