Continuous anticoagulation is often needed to prevent clotting during CRRT in critically ill patients.

Depending on the type of anticoagulation, CRRT poses an increased risk of bleeding.

Recent evidence suggests that RCA provides a longer filter life span while decreasing the risk of bleeding compared to SHA.

RCA is cost-effective vs. SHA despite higher acquisition cost, especially if bleeding leads to longer hospital stays.

More research is needed to assess the impact of bleeding on ICU/hospital stay and confirm RCA’s economic value over SHA.

To evaluate the cost-effectiveness of regional citrate anticoagulation (RCA) or systemic heparin anticoagulation (SHA) during continuous renal replacement therapy (CRRT) in critically ill patients.

A decision-analytic model was developed to calculate an incremental cost-effectiveness ratio between RCA and SHA from a US healthcare payer perspective. Key differentiator was the risk of bleeding derived from the RCA and SHA groups in the RICH trial. Base case didn't consider the potential impact of bleeding on length of stay (LOS) or mortality. Three scenarios were considered: 1-impact of bleeding on LOS; 2-impact of bleeding on mortality; and 3-impact of bleeding on both LOS and mortality.

Base case: RCA was associated with an incremental cost of +$577 compared with SHA. Scenario 1: RCA resulted in cost savings of -$311. Scenario 2: RCA incurred incremental costs of +$614 for +0.076 incremental QALYs (+$8131/QALY). Scenario 3: RCA appeared to be a dominant strategy over SHA. Sensitivity analyses showed the results were robust to parameter uncertainties.

RCA is an economically attractive alternative to SHA, especially when bleeding leads to longer hospital stays. Observational research is warranted to document the impact of bleeding on LOS to confirm the economic value of RCA over SHA.

Continuous renal replacement therapy

Anticoagulation

Regional citrate anticoagulation

Heparin

Cost-effectiveness

Bleeding

© 2025 The Authors. Published by Elsevier Inc.