Supplementary Material for: 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.

引言：连续性肾脏替代治疗（continuous renal replacement therapy, CRRT）的抗凝方案可采用全身抗凝或局部枸橼酸抗凝（regional citrate anticoagulation, RCA）。2012年改善全球肾脏病预后组织（Kidney Disease Improving Global Outcomes, KDIGO）指南明确推荐，无论是否合并出血风险，需接受CRRT的患者均优先采用RCA方案。在重症监护病房（intensive care unit, ICU）实施RCA需要全体医护人员协同配合。本研究的首要目标是梳理并阐述法国重症监护病房内CRRT常用的各类抗凝策略；次要目标为明确RCA的临床应用率，并识别限制其推广应用的关键因素。
方法：本研究于2021年5月至9月期间，向法国重症监护病房执业的主治医师及专科医师受训者发放一份包含40个问题的在线问卷。问卷通过多个渠道发放：法国麻醉与重症医学学会的官方邮件列表，以及肾脏替代治疗（renal replacement therapy, RRT）设备制造商的邮件列表。
结果：本研究共纳入597份有效回复进行分析。结果显示，多数受试者在合并（81%）或未合并（80%）出血风险升高的患者中均采用了RCA方案。受试者使用RCA时首选的CRRT模式为连续性静脉-静脉血液透析（Continuous Veno-venous Hemodialysis, CVVHD），占比达48%。被频繁列为RCA绝对禁忌证的临床场景包括：伴肝功能衰竭的难治性休克，以及影响枸橼酸代谢的药物中毒，占比分别为62%和52%。当面临枸橼酸蓄积风险升高的情况时，多数受试者表示会加强生物指标监测（57%）或调整CRRT治疗方案（61%）。在未将RCA作为一线抗凝方案的受试者中，限制其应用的主要因素为护士（50%）或医师（34%）培训不足。
结论：RCA是法国临床中用于CRRT的主流抗凝方案。为医护人员提供便捷的培训渠道，有助于提升其对RCA的认知水平，并推动其作为CRRT一线抗凝方案的临床应用。