Christina Sudyk, PharmD,
Pediatric Clinical Pharmacist Generalist
University of Michigan Health System Mott Children's Hospital
Ann Arbor, MI
Disclosure information not submitted.
Christopher Michaud, BCCCP, BCPS, PharmD
Pharmacist
Spectrum Health Butterworth Hospital, United States
Disclosure information not submitted.
Sidney Hann, MS
Engineer, Data Analytics
Spectrum Health, United States
Disclosure information not submitted.
Jessica Parker, MS, GStat
Biostatistician Lead
Spectrum Health, United States
Disclosure information not submitted.
Matthew Gurka, BCCCP, PharmD
Pharmacist
Spectrum Health Butterworth Hospital, United States
Disclosure information not submitted.
Title: Cost and Efficacy: Citrate-Based Versus Non-Citrate-Based Continuous Renal Replacement Therapy
INTRODUCTION/HYPOTHESIS: Unfractionated heparin (UH) and citrate are two common anticoagulating agents for continuous renal replacement therapy (CRRT). UH can be utilized to provide systemic or regional anticoagulation while citrate provides regional anticoagulation alone. Although citrate has been shown to prolong filter life compared to UH, data on overall cost-effectiveness is limited. This study assesses overall cost and efficacy between these anticoagulation strategies.
Methods: This single institution, retrospective observational study included adult patients requiring CRRT between Nov. 6, 2017 and Sept. 27, 2019. Patients were eligible if they only received one form of anticoagulation for the entirety of their CRRT run and were excluded if CRRT lasted < 72 hours. Patients were stratified into citrate-based or non-citrate-based anticoagulation arms. The non-citrate group included those who received systemic heparin, circuit-only heparin, or no anticoagulation. The primary outcome was overall cost (USD) associated with CRRT per patient per day. Secondary outcomes included mean circuit duration, cause of circuit change, percent effluent dose delivered, and safety outcomes.
Results: Of the included 217 first CRRT runs, 156 utilized citrate. In the non-citrate arm, 38 patients did not utilize an anticoagulation strategy, three received regional heparin, and 20 systemic heparin. The non-citrate cohort had higher rates of baseline liver dysfunction (63.9% vs. 34.6%, P< 0.01). Overall, citrate patients had a higher cost of CRRT per day ($1276 vs. $887, P< 0.01). Major drivers of cost included calcium monitoring, calcium replacement, and citrate. The non-citrate arm had a longer filter duration (19.8 hours vs. 15.7 hours, P< 0.01). The most common filter discontinuation reason was filter clotting, which was higher in the non-citrate group (33.3% vs. 25.4%, P=0.02). No difference was detected in percent effluent dose delivered (P=0.30). The non-citrate arm had higher rates of reported major bleeds during CRRT (36% vs. 14.7%, P< 0.01).
Conclusions: Despite higher rates of filter clotting in the non-citrate arm, efficacy of CRRT and other related outcomes did not differ between groups. Citrate was a less cost-effective CRRT anticoagulation strategy when compared to non-citrate-based strategies.