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Regional Citrate Anticoagulation and Infectious Complications in Critically Ill Children and Young Adults Receiving
Katja M Gist1, Sai Prasad N Iyer2, H David Humes3
1Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, Colorado, USA, katja.gist@cuanschutz.edu.
Insights
Regional citrate anticoagulation (RCA) did not increase infection risk in pediatric patients undergoing continuous renal replacement therapy (CRRT). Longer time to fluid balance was linked to infection, suggesting a modifiable factor for future research.
Area of Science:
- Nephrology
- Critical Care Medicine
- Pediatric Intensive Care
Background:
- Emerging evidence suggests a link between regional citrate anticoagulation (RCA) and infectious complications during continuous renal replacement therapy (CRRT).
- The association between RCA and infection risk in pediatric populations undergoing CRRT remains unclear.
Purpose of the Study:
- To investigate the association between RCA and culture-positive infectious complications in children and young adults receiving CRRT.
- To identify potential risk factors for infection in this patient group.
Main Methods:
- Secondary analysis of the WE-ROCK registry (2015-2018) involving 874 patients (analysis 1) and 283 patients (analysis 2).
- Exclusion criteria were applied to isolate the effect of anticoagulation on infection, excluding early mortality, trauma, postsurgical status, pre-existing sepsis, and chronic immunosuppression.
- Multivariable logistic and Cox regression models were used to assess the relationship between anticoagulation type and culture-positive infection.
Main Results:
- Culture-positive infection rates were 25% and 17% in the two analyses.
- While univariable analysis showed higher infection rates with RCA, multivariable analysis revealed no significant association between RCA and infection.
- No difference in infection frequency was observed across anticoagulation types in analysis 2.
- A prolonged time to achieve the first negative fluid balance was significantly associated with culture-positive infection.
Conclusions:
- Regional citrate anticoagulation was not associated with an increased risk of culture-positive infection in pediatric and young adult patients undergoing CRRT.
- Systemic effects of acute kidney injury (AKI) and delayed fluid balance achievement may be key factors inciting infection.
- Identifying and modifying these factors presents a potential target for future research and intervention in high-risk CRRT populations.
Introduction:
Recent studies have identified an association between regional citrate anticoagulation (RCA) and subsequent infectious complications during continuous renal replacement therapy (CRRT). We aimed to determine if RCA was associated with infectious complications in children and young adults receiving CRRT.
Methods:
A secondary analysis of the multinational Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry (34 centers, 9 countries), was performed, including patients from 2015 to 2018. Patients were excluded if they (1) died within 72 h of CRRT initiation, had minor trauma or were postsurgical (analysis 1), or (2) met an exclusion in analysis 1 or had sepsis prior to CRRT initiation or chronic immunosuppression (analysis 2). Multivariable mixed-effects logistic (analysis 1) and mixed-effects Cox regression (analysis 2) were used to determine the associations between anticoagulant type and culture-positive infection after CRRT initiation.
Results:
A total of 874 patients were included in analysis 1 and 283 in analysis 2. Culture-positive infection occurred in 25% and 17% of each analysis. In analysis 1, culture-positive infection was higher in RCA (29%) vs. heparin (23%) and other (15%); p = 0.008. There was no association between RCA and infection in multivariable analysis. In analysis 2, there was no difference in the frequency of infection by anticoagulation type. A longer time to achieve the first negative fluid balance was associated with culture-positive infection.
Conclusion:
RCA was not associated with culture-positive infection after CRRT initiation in this study. The systemic effects of AKI and longer time to first negative fluid balance may be inciting factors for an infection and represent a potentially modifiable factor that warrants future studies in this high-risk population.
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