Investigating Different Anticoagulants for Renal Replacement Therapy (RICH)


University Hospital Muenster

Status and phase

Phase 4


Acute Kidney Injury


Drug: Citrate
Drug: Heparin

Study type


Funder types



2014-004854-33 (EudraCT Number)
UKM 14_0066
03-AnIt-14 (Other Identifier)

Details and patient eligibility


The aim of this study is to evaluate the effect of regional citrate anticoagulation within the scope of continuous renal replacement (CRRT) in critically ill patients with acute kidney injury (AKI) on filter life span and 90-day all cause mortality.

Full description

Purpose of clinical trial: To evaluate the effect of regional citrate anticoagulation within the scope of continuous renal replacement (CRRT) in critically ill patients with acute kidney injury (AKI) on filter life span and 90-day all cause mortality. Patient population: critically ill patients with acute kidney injury requiring renal replacement therapy. Primary objective: Anticoagulation of the extracorporeal circuit is required in continuous RRT (CRRT). To this date, it is not clear which anticoagulant should be used for CRRT. Regional citrate anticoagulation (RCA) for CRRT in critically ill patients with AKI prolongs filter life span and reduces 90-day all cause mortality by approximately 8% (from 48% to 40%) compared to systemic heparin anticoagulation for CRRT


638 patients




18 to 90 years old


No Healthy Volunteers

Inclusion criteria

  1. Critically ill patients with clinical indication for CRRT (clinical decision to use continuous RRT due to hemodynamic instability)


    Severe acute kidney injury (KDIGO 3-classification) despite optimal resuscitation

  2. At least one of the following conditions

    • Sepsis or septic shock
    • Use of catecholamines (norepinephrine or epinephrine ≥ 0.1 µg/kg/min or norepinephrine ≥ 0.05 µg/kg/min + dobutamine (any dose) or norepinephrine ≥ 0.05 µg/kg/min + vasopressin (any dose) or epinephrine ≥ 0.05 µg/kg/min + norepinephrine ≥ 0.05 µg/kg/min)
    • Refractory fluid overload: worsening pulmonary edema: PaO2/FiO2 < 300 mmHg and/or fluid balance > 10% of body weight)
  3. 18-90 years old

  4. Intention to provide full intensive care treatment for at least 3 days

  5. Written informed consent of the patient or the legal representatives or the authorized representative or the inclusion due to an emergency situation

Exclusion criteria

  1. Patients with increased bleeding risk (e.g. an active bleeding from ulcers in the gastro-intestinal tract, hypertension with a diastolic blood pressure higher than 105 mm Hg, injuries (intracranial hemorrhage, aneurysm of brain arteries) of or surgical procedures on the central nervous system if a heparinization with a target aPTT 45-60 s is not allowed by the treating neurologist or neurosurgeon, severe retinopathies, bleeding into the vitreum, ophthalmic surgical procedures)) or injuries, active tuberculosis; infective endocarditis)
  2. Disease or organ damage related with hemorrhagic diathesis (coagulopathy, thrombocytopenia, severe liver or pancreas disease)
  3. Dialysis-dependent chronic kidney insufficiency
  4. Need of therapeutic systemic anticoagulation
  5. Allergic reaction to one of the anticoagulants or ingredients, Heparin-induced thrombocytopenia
  6. AKI caused by permanent occlusion or surgical lesion of the renal artery
  7. AKI caused by (glomerulo)nephritis, interstitial nephritis, vasculitis or postrenal obstruction
  8. Do-not-resuscitate order
  9. Hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura
  10. Persistent and severe lactate acidosis in the context of an acute liver failure and/or shock
  11. Kidney transplant within the last 12 months
  12. Pregnancy and nursing period
  13. Abortus imminens
  14. No hemofiltration machine free for use at the moment of inclusion
  15. Participation in another clinical intervention trial in the last 3 months
  16. Persons with any kind of dependency on the investigator or employed by the sponsor or investigator
  17. Persons held in an institution by legal or official order

Trial design

Primary purpose




Interventional model

Parallel Assignment


None (Open label)

638 participants in 2 patient groups

heparin anticoagulation
Active Comparator group
Systemic anticoagulation of the continuous renal replacement therapy with heparin. Dose will be titrated to maintain aPTT (activated partial thromboplastin time) between 45-60s)
Drug: Heparin
citrate anticoagulation
Experimental group
Regional anticoagulation of the continuous renal replacement therapy with citrate. Target posthemofilter ionized calcium level: 0.25-0.35 mmol/l
Drug: Citrate

Trial contacts and locations



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