TOP 47 - Comparing Safety and Efficacy Between Regional Citrate, Unfractionated Heparin, and Bivalirudin in Pediatric Continuous Kidney Replacement Therapy

Publication Number: 1806.TOP 47

Bahar Barani, Children's Mercy Hospital, Overland Park, KS, United States; Darcy Weidemann, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Charley Spear, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; Naile T. Tufan Pekkucuksen, Children's Mercy, Kansas City, MO, United States

Background: Appropriate anticoagulation strategies are paramount to a successful continuous kidney replacement therapy (CKRT) program to minimize treatment disruption and prevent adverse effects. Current clinical practice guidelines recommend either regional citrate anticoagulation (RCA) or unfractionated heparin (UFH), although interest in alternative anticoagulation strategies have grown. Bivalirudin, a systemic anticoagulant, is a direct thrombin inhibitor which offers several advantages over traditional anticoagulation strategies due to its short half-life, predictable anticoagulant effect, ease of therapeutic monitoring and adjustment, and potential for reduced risk of heparin-induced thrombocytopenia. However, limited pediatric studies have directly compared safety and efficacy in bivalirudin versus traditional anticoagulation strategies in children receiving CKRT. Understanding this data would allow for new guidelines for usage of alternative anticoagulation strategies in children.

Objective: Compare the filter life and safety profiles of CKRT circuits using RCA, UFH, bivalirudin, and no anticoagulation.

Design/Methods: Retrospective analysis of all pediatric patients ages 0-22 years of age who received CKRT at a stand-alone pediatric hospital between January 1, 2014, through December 31, 2024. Patients identified by ICD9/ICD10 codes and prospectively maintained quality improvement program databases. All analyses for pilot population performed using STATA/IC 16.1. The primary outcome is the number of hours a single CKRT filter was in use with notation for unplanned circuit changes due to circuit clotting related complications. Safety was assessed by comparing patient survival, bleeding outcomes including brain bleed and gastrointestinal bleed, and metabolic disturbances. Metabolic disturbances included alkalosis requiring change of anticoagulation method and citrate lock. Descriptive statistics performed using X. ANOVA or Kruskal-Wallis tests were performed to compare filter life. A pilot population has been collected for the purpose of this abstract with analysis on a sample size of 27 children (9 female and 18 male) aged 1 day to 18 years old [Mean age: 6.2 SD: 5.7]. A total of 8,911 hours of treatment time was compared using 180 filters. This preliminary data is broken down to highlight unexpected circuit changes, gastrointestinal bleeding, and intracranial bleeding. 93 charts remain for analysis to achieve appropriate power for a non-inferiority evaluation. The data analysis plan will be to collect remaining chart data by December 31, 2025.

Pilot Population Characteristics and Preliminary Findings
Figure 1 .pdfKey demographic and clinical variables are presented in Table 1. In this retrospective cohort study, the pilot data included 27 children (9 female and 18 male) aged 1 day to 18 years old [Mean age: 6.2 SD: 5.7]. All children underwent CKRT with the Prismax® or Prismaflex® machines. The most common indications were AKI and fluid overload. A total of 8,911 hours of treatment time was compared using 180 filters. The mean filter life was 49h [SD: 26.7 min: 3h, max: 103h]. 49 filters with RCA, 108 filters with bivalirudin, 10 filters heparin, 4 filters with both RCA and bivalirudin, 9 filter without anticoagulation. There was no statistical difference between filter life between anticoagulation types (p: 0.13). 5 patients experienced brain bleeding, 3 of them were on bivalirudin, 1 of them was on RCA,1 was without anticoagulation. One patient experienced GI bleeding with bivalirudin. 6 patients experienced metabolic alkalosis as a side effect of citrate then were switched to bivalirudin. No reported citrate lock.

Pilot Population Filter Life Summary
Filter Life Summary.pdfFilter life summary with the various anticoagulation types.