Author(s)

Yunchuan Zhong ¹, Li Shi ¹, Yongsheng Qi ¹

Affiliation(s)

¹ Emergency Department, The First People's Hospital of Neijiang, Neijiang, Sichuan, China

Corresponding Author

Yunchuan Zhong

ABSTRACT

Optimal anticoagulation strategy for continuous renal replacement therapy (CRRT) in critically ill patients with high bleeding risk remains controversial. This study retrospectively evaluated the real-world effectiveness and safety of three anticoagulation approaches in continuous veno-venous hemodialysis (CVVHD). We conducted a multicenter retrospective cohort study analyzing 168 ICU patients with acute kidney injury and high bleeding risk (HAS-BLED score ≥3) who underwent CVVHD between January 2022 and April 2025 at three tertiary hospitals in Sichuan Province, China. Based on the anticoagulation strategy chosen by treating physicians, patients were classified into three groups: Group A - low-dose systemic heparin (n=62); Group B - regional citrate anticoagulation (n=54); Group C - heparin-free protocol with saline flushing (n=52). Primary outcomes included filter lifespan and major bleeding events. Secondary outcomes encompassed metabolic complications, inflammatory markers, and 28-day mortality. Propensity score matching was performed to minimize selection bias. After propensity score matching (40 patients per group), median filter lifespan differed significantly among groups (A: 41.3 [IQR 27.5-55.2] h, B: 65.7 [IQR 48.9-82.5] h, C: 29.8 [IQR 20.4-39.2] h; p<0.001). Major bleeding events occurred in 25.0% (10/40) of Group A, 10.0% (4/40) of Group B, and 7.5% (3/40) of Group C patients (p=0.008). Group B demonstrated superior metabolic stability with fewer episodes of metabolic alkalosis (5.0% vs 17.5% vs 12.5%, p=0.041). Inflammatory markers (IL-6, CRP, PCT) showed comparable reduction across all groups. The 28-day mortality rates were 32.5%, 25.0%, and 30.0% for Groups A, B, and C, respectively (p=0.651). Multivariate Cox regression identified APACHE II score (HR 1.09, 95% CI 1.05-1.13), vasopressor requirement (HR 2.28, 95% CI 1.58-3.29), and baseline platelet count <50×10⁹/L (HR 1.92, 95% CI 1.29-2.86) as independent mortality predictors, while anticoagulation strategy was not significantly associated with mortality after adjustment. In real-world practice, regional citrate anticoagulation demonstrated superior filter longevity and reduced bleeding complications compared to low-dose heparin in high-bleeding-risk patients. Heparin-free CVVHD showed the lowest bleeding rates but required more frequent filter changes. These findings support individualized anticoagulation selection based on bleeding risk assessment and institutional capabilities.

KEYWORDS

Continuous Renal Replacement Therapy; Anticoagulation; Bleeding Risk; Citrate; Heparin-Free; Retrospective Study; Critical Care

CITE THIS PAPER

Yunchuan Zhong, Li Shi, Yongsheng Qi, Comparative Effectiveness and Safety of Three Anticoagulation Strategies in Continuous Veno-Venous Hemodialysis for Critically Ill Patients with High Bleeding Risk: A Multicenter Retrospective Cohort Study. MEDS Clinical Medicine (2025) Vol. 6: 109-119. DOI: http://dx.doi.org/10.23977/medsc.2025.060318.

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