Continuous Renal Replacement Therapy in COVID-19-associated AKI: Adding Heparin to Citrate to Extend Filter Life – a Retrospective Cohort

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), submitted to CRRT. Filter clotting risks in the first 72 hours were compared between groups.Results: Between January 2019 and July 2020, 248 patients were evaluated: 189 in the COV+ AKI group and 59 in the COV− AKI group. Filter clotting occurred during the first 72 hours of CRRT in 96 patients (38.7%). Heparin use conferred protection against filter clotting, 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 (6086 ng/ml). In the multivariate analysis, the protective effect of heparin against filter clotting persisted, whereas an elevated D-dimer level, high platelet count, and high hemoglobin were found to be risk factors for circuit clotting. A diagnosis of COVID-19 was not a risk factor for filter clotting.Conclusions: In COV+ AKI patients, adding systemic heparin to standard regional citrate anticoagulation may prolong CRRT filter patency by reducing clotting risk with low risk of complications.