Citrate Versus Heparin Anticoagulation: Effect on Molecules Clearances

Summary

Sepsis is responsible for 50% of all acute kidney injury (AKI) in intensive care units (ICUs), contributing greatly to multiple organ dysfunction syndrome (MODS). Special types of continuous renal replacement therapies (CRRT) have been proposed as adjuvant therapies for septic shock due to their ability to remove middle molecular weight molecules such as inflammatory mediators involved in MODS pathophysiology. These therapies are called extracorporeal " blood purification " therapies.

When CRRT is used, an anticoagulation is required to prevent clotting of the extracorporeal circuit, possibly causing bleeding in selected patients. Many anticoagulation strategies have been proposed and the most commonly used in 2013 is still unfractionated heparin. Regional citrate anticoagulation (RCA) is an interesting alternative as it dramatically decreases the bleeding risk.

The investigators hypothesize that the use of citrate with Super High Flux Continuous Veno-Venus Hemodialysis (SHF-CVVHD) would be highly beneficial over time by preserving the filter effectiveness via limiting protein adhesion (which subsequently reduces filter pore sizes (protein cake)), as compared to heparin. Consequently, higher clearances of the inflammatory mediators could be maintained over time with citrate as compared to heparin anticoagulation. In other words, for the same duration of filter use, middle molecular weight molecules and cytokines clearances would be greater with citrate as compared to heparin. To test this hypothesis, the investigators will perform a clinical randomized controlled trial which aim would be to compare middle molecular weight molecules and cytokines clearances in SHF-CVVHD using RCA versus systemic heparin anticoagulation in septic patients with AKI.

Conditions

• Septic Shock

Interventions

DRUG

Anticoagulation to prevent clotting of the extracorporeal circuit. (regional citrate anticoagulation)

Anticoagulation to prevent clotting of the extracorporeal circuit. Unfractionated heparin and regional citrate anticoagulation will be compared. Ci-Ca protocole for MultiFiltrate® CRRT machine : * 4% trisodium citrate solution * Calcium chloride solution (100 mmol/L) * Dialysate flow rate: 35 ml/kg/h * Blood flow rate: adjusted to maintain a ratio blood flow rate / dialysate flow rate of 3 * Citrate infusion titrated to maintain postfilter ionized calcium between 0.25 and 0.35 mmol/L. * Calcium chloride infusion titrated to maintain systemic ionized calcium between 1.12 and 1.2 mmol/L. * Blood flow adapted to the acid-base status

DRUG

Anticoagulation to prevent clotting of the extracorporeal circuit (Unfractionated heparin)

Anticoagulation to prevent clotting of the extracorporeal circuit. Unfractionated heparin and regional citrate anticoagulation will be compared. * Continuous infusion of unfractionated heparin: starting infusion rate at 600 IU/h then adjusted to maintain partial thromboplastin time at 1-1.4 times the normal value. * Standard dialysate for CRRT : Prismasol® K2 solution * Dialysate flow rate: 35 ml/kg/h * Blood flow rate: adjusted to maintain a ratio blood flow rate / dialysate flow rate of

Sponsors & Collaborators

• Hospices Civils de Lyon

  lead OTHER

Study Design

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2013-05-31

Primary Completion

2014-11-30

Completion

2015-04-30

Countries

• France

Study Locations