Anticoagulation strategies for continuous renal replacement therapy in France: a survey of practices

Introduction: Anticoagulation for continuous renal replacement therapy (CRRT) can be performed using systemic anticoagulation or regional citrate anticoagulation (RCA). The 2012 Kidney Disease Improving Global Outcomes guidelines support the use of RCA as the first-line strategy in patients requiring CRRT, with and without bleeding risk. Implementing RCA in the intensive care unit (ICU) implies to involve all medical and nursing staff. The primary objective of this study was to report and describe the various anticoagulation strategies for CRRT in French ICUs. The secondary objectives were to determine the rate of RCA use and to identify the factors limiting its implementation. Methods: An online questionnaire containing 40 questions was sent to attending physicians and fellows practicing in French ICUs between May and September 2021. The questionnaire was sent via several networks: mailing list from the French society of anesthesia and intensive care medicine, and mailing lists of RRT manufacturers. Results: A total of 597 responses were analyzed. RCA was used by most of the participants for patients with (81%) and without (80%) increased bleeding risk. The preferred CRRT modality of the participants while using RCA was Continuous Veno-venous Hemodialysis (48%). The clinical situations frequently reported as an absolute contraindication to RCA were uncontrolled shock associated with liver failure and drug poisoning impairing citrate metabolism (62% and 52%, respectively). In case of a higher risk of citrate accumulation, most participants claimed to perform a closer biological monitoring (57%) or to modify the CRRT protocol (61%). Among the participants who did not prescribe RCA as first-line strategy, the main factors limiting its implementation were the lack of nurse (50%) or physician (34%) training. Conclusion: RCA is the main anticoagulation strategy prescribed for CRRT in France. Providing to medical and nursing staff an easy access to training may facilitate the understanding and use of RCA as the first-line anticoagulation strategy for CRRT.