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Idrovo A, Afonso N, Price J, Tume S, Akcan-Arikan A. Kidney replacement therapy in pediatric patients on mechanical circulatory support: challenges for the pediatric nephrologist. Pediatr Nephrol 2021; 36:1109-1117. [PMID: 32462258 DOI: 10.1007/s00467-020-04605-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022]
Abstract
The use of mechanical circulatory support (MCS) therapies in children with medically refractory cardiac failure has increased over the past two decades. With the growing experience and expertise, MCS is currently offered as a bridge to recovery or heart transplantation and in some cases even as destination therapy. Acute kidney injury (AKI) is common in patients with end-stage heart failure (ESHF). When severe AKI develops requiring kidney replacement therapy (KRT), these patients present unique challenges for the pediatric nephrology team. The use of KRT has not been adequately described in children with ESHF on the newer MCS. We also present original case series data from our center experience. The purpose of this review is to familiarize the reader with the current MCS technologies, approach to their selection, how they interact when combined with current KRT circuits, and distinguish similarities and differences. We will attempt to highlight the distinctive features of each technology, specifically focusing on growing trends in use of continuous-flow ventricular assist devices (CF-VAD) as it poses additional challenges to the pediatric nephrologist.
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Affiliation(s)
- Alexandra Idrovo
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates St., Suite 245, Houston, TX, 77030, USA.
| | - Natasha Afonso
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jack Price
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.,Department of Pediatrics, Cardiology Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sebastian Tume
- Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates St., Suite 245, Houston, TX, 77030, USA.,Department of Pediatrics, Critical Care Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Williams NX, Carroll B, Noyce SG, Hobbie HA, Joh DY, Rogers JG, Franklin AD. Fully printed prothrombin time sensor for point-of-care testing. Biosens Bioelectron 2020; 172:112770. [PMID: 33157410 DOI: 10.1016/j.bios.2020.112770] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/25/2020] [Indexed: 01/14/2023]
Abstract
With an increasing number of patients relying on blood thinners to treat medical conditions, there is a rising need for rapid, low-cost, portable testing of blood coagulation time or prothrombin time (PT). Current methods for measuring PT require regular visits to outpatient clinics, which is cumbersome and time-consuming, decreasing patient quality of life. In this work, we developed a handheld point-of-care test (POCT) to measure PT using electrical transduction. Low-cost PT sensors were fully printed using an aerosol jet printer and conductive inks of Ag nanoparticles, Ag nanowires, and carbon nanotubes. Using benchtop control electronics to test this impedance-based biosensor, it was found that the capacitive nature of blood obscures the clotting response at frequencies below 10 kHz, leading to an optimized operating frequency of 15 kHz. When printed on polyimide, the PT sensor exhibited no variation in the measured clotting time, even when flexed to a 35 mm bend radius. In addition, consistent PT measurements for both chicken and human blood illustrate the versatility of these printed biosensors under disparate operating conditions, where chicken blood clots within 30 min and anticoagulated human blood clots within 20-100 s. Finally, a low-cost, handheld POCT was developed to measure PT for human blood, yielding 70% lower noise compared to measurement with a commercial potentiostat. This POCT with printed PT sensors has the potential to dramatically improve the quality of life for patients on blood thinners and, in the long term, could be incorporated into a fully flexible and wearable sensing platform.
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Affiliation(s)
- Nicholas X Williams
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Brittani Carroll
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Steven G Noyce
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Hansel Alex Hobbie
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Daniel Y Joh
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
| | - Joseph G Rogers
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, NC, 27708, USA
| | - Aaron D Franklin
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA; Department of Chemistry, Duke University, Durham, NC, 27708, USA.
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Buturovic-Ponikvar J. Is Regional Citrate Anticoagulation the Future of Hemodialysis? Ther Apher Dial 2017; 20:234-9. [PMID: 27312907 DOI: 10.1111/1744-9987.12429] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022]
Abstract
Citrate has many characteristics of the ideal anticoagulant for hemodialysis. In addition to immediate and complete anticoagulation in the dialysis circuit, citrate has important effects beyond anticoagulation, mainly in reducing inflammatory response induced by hemodialysis. Citrate has already become the standard anticoagulant in acute kidney injury requiring continuous renal replacement therapy (CRRT), both for adults and children, with the citrate module being a part of modern CRRT monitors. Although the citrate module is not yet available for intermittent hemodialysis, precise infusion pumps, point-of-care ionometers and high citrate clearance from high flux dialyzers increase safety while reducing the risk of metabolic complications, both in adult and pediatric patients. Slovenia has a long tradition, high volume and expansion of citrate use in hemodialysis, including long-term citrate anticoagulation in selected patients. At the Department of Nephrology, University Medical Centre Ljubljana, more than 10 000 citrate procedures were performed in 2015. We believe that regional citrate anticoagulation may replace heparin as the main anticoagulant for intermittent hemodialysis in the not so distant future.
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Affiliation(s)
- Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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The role of ionized calcium and magnesium in regional citrate anticoagulation and its impact on inflammatory parameters. Int J Artif Organs 2017; 40:15-21. [PMID: 28218351 DOI: 10.5301/ijao.5000558] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Regional anticoagulation with citrate has been found to be superior to heparin in terms of biocompatibility, and numerous protocols for regional citrate anticoagulation have been published, while a consensus on the target concentration of ionized calcium (Ca2+) in the extracorporeal circuit has not been reached so far. METHODS The aim of this in vitro study was to assess the impact of different citrate concentrations on coagulation as well as on complement activation and cytokine secretion and to investigate the impact of ionized magnesium (Mg2+) on these parameters. RESULTS We found that citrate effectively reduced coagulation, complement activation, and cytokine secretion in a dose-dependent manner and that a target Ca2+ concentration of 0.2-0.25 mM was required for efficient anticoagulation. Mg2+ triggered complement activation as well as interleukin (IL)-1β secretion in lipopolysaccharide (LPS)-stimulated whole blood in a dose-dependent manner and independently of Ca2+. Additionally, it was found to reduce activated clotting time (ACT) in samples with low Ca2+ levels, but not at physiological Ca2+. CONCLUSIONS Taken together, our data support the notion that regional citrate anticoagulation results in decreased release of inflammatory mediators in the extracorporeal circuit, requiring the depletion of both, Ca2+ and Mg2+.
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Singer RF, Williams O, Mercado C, Chen B, Talaulikar G, Walters G, Roberts DM. Regional citrate anticoagulation in hemodialysis: an observational study of safety, efficacy, and effect on calcium balance during routine care. Can J Kidney Health Dis 2016; 3:22. [PMID: 27099775 PMCID: PMC4837599 DOI: 10.1186/s40697-016-0113-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 04/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regional citrate hemodialysis anticoagulation is used when heparin is contraindicated, but most protocols require large infusions of calcium and frequent intradialytic plasma ionized calcium measurements. OBJECTIVES The objective of this study was to determine the safety, efficacy, and effect on calcium balance of regional citrate anticoagulation using sparse plasma ionized calcium sampling. DESIGN The design of this study was observational. SETTING The setting of this study was the hospital hemodialysis center. PATIENTS The subjects of this study were the hospital hemodialysis patients. MEASUREMENTS Dialysate calcium concentration by atomic absorption spectroscopy and total dialysate weight were used as measurements. METHODS Regional citrate anticoagulation was introduced using zero calcium dialysate, pre-dialyzer citrate infusion, and post-dialyzer calcium infusion. Infusions were adjusted based on pre- and post-dialyzer calcium measurements obtained at least twice during a 4-h dialysis. The protocol was simplified after the first 357 sessions to dispense with post-dialyzer calcium measurements. Heparin-anticoagulated sessions were performed using acetate-acidified 1.25 mmol/L calcium or citrate-acidified 1.5 mmol/L calcium dialysate. Calcium balance assessment was by complete dialysate recovery. Safety and efficacy were assessed prospectively using a point-of-care database to record ionized calcium and clinical events. Groups were compared using t test, ANOVA, Wilcoxon rank sum, or Kruskal-Wallis as appropriate. RESULTS Seventy-five patients received regional citrate-anticoagulated dialysis over 1051 dialysis sessions. Of these, 357 dialysis sessions were performed using the original citrate anticoagulation protocol and 694 using the simplified protocol. Dialysis was effective and safe. Only 3 dialyzers clotted; 1 patient suffered symptomatic hypercalcemia and none suffered symptomatic hypocalcemia. Calcium balance was assessed in 15 regional citrate-anticoagulated dialysis sessions and 30 heparin-anticoagulated sessions. The median calcium loss was 0.8 mmol/h dialyzed in both groups (p = 0.43), and end of treatment ionized calcium was the same in both groups (1.07 ± 0.04 mmol/L). LIMITATIONS Our findings for calcium balance, efficacy, and safety are valid only for the protocol studied, which excluded patient with severe liver dysfunction. CONCLUSIONS Regional citrate dialysis can be performed safely and effectively using a sparse plasma calcium sampling protocol. The calcium balance induced by this protocol is not different to that seen in standard heparin-anticoagulated dialysis, but in the absence of prospective studies, it is unknown whether this is optimal for patient care.
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Affiliation(s)
- Richard F. Singer
- />The Australian National University, Acton, Australia
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
| | | | - Chari Mercado
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
| | - Bonny Chen
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
| | - Girish Talaulikar
- />The Australian National University, Acton, Australia
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
| | - Giles Walters
- />The Australian National University, Acton, Australia
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
| | - Darren M. Roberts
- />The Australian National University, Acton, Australia
- />The Canberra Hospital, Level 2, Building 15, PO Box 11, Woden, 2606 Australia
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Soltysiak J, Warzywoda A, Kociński B, Ostalska-Nowicka D, Benedyk A, Silska-Dittmar M, Zachwieja J. Citrate anticoagulation for continuous renal replacement therapy in small children. Pediatr Nephrol 2014; 29:469-75. [PMID: 24337319 PMCID: PMC3913856 DOI: 10.1007/s00467-013-2690-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 10/07/2013] [Accepted: 10/29/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is one of the methods used to prevent clotting in continuous renal replacement therapy (CRRT). The aim of this study was to describe the outcomes and complications of RCA-CRRT in comparison to heparin anticoagulation (HA)-CRRT in critically ill children. METHODS This study was a retrospective review of 30 critically ill children (16 on RCA- and 14 on HA-CRRT) who underwent at least 24 h of CRRT. The mean body weight of the children was 8.69 ± 5.63 kg. RCA-CRRT was performed with a commercially available pre-dilution citrate solution (Prismocitrate 18/0). RESULTS The mean time on RCA-CRRT and HA-CRRT was 148.73 ± 131.58 and 110.24 ± 105.38 h, respectively. Circuit lifetime was significantly higher in RCA-CRRT than in HA-CRRT (58.04 ± 51.18 h vs. 37.64 ± 32.51 h, respectively; p = 0.030). Circuit clotting was observed in 11.63 % of children receiving RCA-CRRT and 34.15 % of those receiving HA-CRRT. Episodic electrolyte and metabolic disturbances were more common in children receiving RCA-CRRT. The survival at discharge from the hospital was 37.5 and 14.3 % among children receiving RCA-CRRT and HA-CRRT, respectively. CONCLUSIONS In critically ill children with a low body weight, RCA appeared to be safe and easy to used. Among our patient cohort, RCA was more effective in preventing circuit clotting and provided a better circuit lifetime than HA.
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Affiliation(s)
- Jolanta Soltysiak
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland,
| | - Alfred Warzywoda
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartłomiej Kociński
- Department of Pediatric Cardiac Surgery, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Danuta Ostalska-Nowicka
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Benedyk
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Silska-Dittmar
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Zachwieja
- Department of Pediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poznan, Poland
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Strobl K, Hartmann J, Wallner M, Brandl M, Falkenhagen D. A target-oriented algorithm for citrate-calcium anticoagulation in clinical practice. Blood Purif 2013; 36:136-45. [PMID: 24217288 DOI: 10.1159/000355012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 08/08/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Because of a high monitoring demand and an ensuing need for automation of regional citrate anticoagulation (RCA), a new semi-automated target-oriented algorithm was developed. The aim of this study was the evaluation of its functionality and safety. METHODS Fourteen haemodialysis patients were treated 5 times consecutively with RCA. Samples were drawn pre- and post-infusion once per hour. Electrolytes, blood cell counts, acid-base and coagulation parameters were analyzed. RESULTS Mean ionized calcium (Ca(2+)) values pre-filter were 0.23 and 0.33 mmol/l in the 0.2 and 0.3 mmol/l target groups, respectively. Extraction ratios for citrate and total calcium through the dialysis filter were constant during the entire treatment (83 and 68%, respectively). Citrate accumulation was avoided. CONCLUSION The new algorithm enables safe and accurate RCA. By regulating Ca(2+) pre-filter using the target-oriented algorithm, the degree of anticoagulation may be easily controlled.
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Affiliation(s)
- Karin Strobl
- Center for Biomedical Technology, Danube University Krems, Krems, Austria
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Davenport A. Alternatives to standard unfractionated heparin for pediatric hemodialysis treatments. Pediatr Nephrol 2012; 27:1869-79. [PMID: 22374405 PMCID: PMC3422452 DOI: 10.1007/s00467-012-2129-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 01/25/2012] [Accepted: 01/27/2012] [Indexed: 12/05/2022]
Abstract
Despite advances in biomaterials and dialyzer design, thrombin generation occurs in the dialysis circuit because of platelet and leukocyte activation. As such, anticoagulation is required by the majority of children for successful dialysis to prevent clotting in the venous air detector and the capillary dialyzer, particularly for small children with slower blood flow rates. For many years unfractionated heparin has been the standard anticoagulant of choice, but is now being challenged by low-molecular-weight heparins (LMWHs) because they are simple to administer and reliable, particularly as the cost differential has been eroded. Alternative, nonheparin anticoagulants are more frequently available, but are often restricted to special circumstances: patients at high risk of hemorrhage; heparin allergy; or heparin-induced thrombocytopenia. These nonheparin alternatives are significantly more expensive than heparins, and may add a degree of complexity, such as citrate, which is a regional anticoagulant, although citrate-containing dialysate may permit short anticoagulant-free dialysis sessions. Systemic anticoagulants required for immune-mediated, heparin-induced thrombocytopenia are expensive and either have short half-lives, and therefore require continuous infusions, or prolonged half-lives, which, although allowing simple bolus administration, increases the risk of drug accumulation, over-dosage and hemorrhage.
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Affiliation(s)
- Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, Rowland Hill Street, London, NW3 2PF, UK.
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Sohn YB, Paik KH, Cho HY, Kim SJ, Park SW, Kim ES, Chang YS, Park WS, Choi YH, Jin DK. Continuous renal replacement therapy in neonates weighing less than 3 kg. KOREAN JOURNAL OF PEDIATRICS 2012; 55:286-92. [PMID: 22977441 PMCID: PMC3433565 DOI: 10.3345/kjp.2012.55.8.286] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 01/06/2012] [Accepted: 03/23/2012] [Indexed: 12/31/2022]
Abstract
PURPOSE Continuous renal replacement therapy (CRRT) is becoming the treatment of choice for supporting critically ill pediatric patients. However, a few studies present have reported CRRT use and outcome in neonates weighing less than 3 kg. The aim of this study is to describe the clinical application, outcome, and complications of CRRT in small neonates. METHODS A retrospective review was performed in 8 neonatal patients who underwent at least 24 hours of pumped venovenous CRRT at the Samsung Medical Center in Seoul, Korea, between March 2007 and July 2010. Data, including demographic characteristics, diagnosis, vital signs, medications, laboratory, and CRRT parameters were recorded. RESULTS The data of 8 patients were analyzed. At the initiation of CRRT, the median age was 5 days (corrected age, 38(+2) weeks to 23 days), and the median body weight was 2.73 kg (range, 2.60 to 2.98 kg). Sixty-two patient-days of therapy were reviewed; the median time for CRRT in each patient was 7.8 days (range, 1 to 37 days). Adverse events included electrolyte disturbances, catheter-related complications, and CRRT-related hypotension. The mean circuit functional survival was 13.9±8.6 hours. Overall, 4 patients (50%) survived; the other 4 patients, who developed multiorgan dysfunction syndrome, died. CONCLUSION The complications of CRRT in newborns are relatively high. However, the results of this study suggest that venovenous CRRT is feasible and effective in neonates weighing less than 3 kg under elaborate supportive care. Furthermore, for using potential benefit of CRRT in neonates, efforts are required for prolonging filter survival.
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Affiliation(s)
- Young Bae Sohn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Brandl M, Strobl K, Hartmann J, Kellner K, Posnicek T, Falkenhagen D. A target-orientated algorithm for regional citrate-calcium anticoagulation in extracorporeal therapies. Blood Purif 2011; 33:7-20. [PMID: 22085810 DOI: 10.1159/000332394] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/29/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Citrate anticoagulation offers several advantages in comparison to conventional anticoagulation. Most algorithms for regional citrate-calcium anticoagulation are based on citrate and calcium chloride infusion coupled in a fixed proportion to the blood flow without considering the hematocrit (Hct)/plasma flow or the filter clearance of citrate and calcium. METHODS The aim of this study was to develop an algorithm for optimized citrate anticoagulation in extracorporeal therapies such as dialysis. A mathematical model was developed to calculate the volume of citrate infusion required to achieve a desired ionized calcium (iCa) target level in the extracorporeal circuit and to restore the total calcium level to a physiological value. RESULTS The model was validated by correlation analyses for different blood Hct values and shows an excellent fit to the laboratory measurements. CONCLUSION The results for both iCa target concentrations, namely those after citrate and calcium infusion, proved that the software algorithm adapts well to variable treatment parameters.
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Affiliation(s)
- M Brandl
- Center for Biomedical Technology, Danube University Krems, Krems, Austria. martin.brandl @ donau-uni.ac.at
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Wright S, Steinwandel U, Ferrari P. Citrate anticoagulation using ACD solution A during long-term haemodialysis. Nephrology (Carlton) 2011; 16:396-402. [PMID: 21054668 DOI: 10.1111/j.1440-1797.2010.01421.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Haemodialysis with regional citrate anticoagulation in patients with contraindications for heparin is increasingly performed in the USA and Europe. Most published protocols use trisodium citrate, which is not readily available nor is it licensed in Australia. We established a protocol for citrate-anticoagulation in haemodialysis using acid citrate dextrose solution A (ACDA), which is approved for apheresis procedures in Australia. The aim of the present study was to assess the safety and efficacy of this protocol for routine use in haemodialysis patients. METHODS Systemic and post-filter blood ionized calcium, serum sodium and bicarbonate and dialyzer clotting score were analyzed prospectively in 14 patients undergoing 150 consecutive haemodialysis treatments with citrate anticoagulation using calcium-free dialysate. A simple algorithm allowed the attending nurse to adjust citrate infusion (to maintain post-filter ionized calcium at 0.2-0.3 mmol/L) and i.v. calcium substitution. Scheduled dialysis time was 4 h, and point-of-care monitoring of blood ionized calcium during dialysis was done at 0, 15, 60, 120 and 240 min. RESULTS ACDA infusion rates of 300 mL/h were used in the first 52 treatments, but resulted in high dialyzer clotting score and 6% of treatments were discontinued due to complete clotting. Thereafter, ACDA infusion rate was increased to 350 mL/h, with all 98 subsequent treatments completed successfully. Ionized calcium levels were stable during all procedures with post-dialysis serum sodium averaging 135 ± 3 mmol/L and bicarbonate 23.8 ± 2 mmol/L. CONCLUSION Routine use of citrate anticoagulation in the setting of a long-term haemodialysis unit is safe and efficient. Point-of-care measurements of ionized calcium levels are critical to safely and successfully perform citrate anticoagulation.
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Affiliation(s)
- Stephen Wright
- Department of Nephrology, Fremantle Hospital, Perth, Western Australia, Australia
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Kreuzer M, Ahlenstiel T, Kanzelmeyer N, Ehrich JHH, Pape L. Regional citrate anticoagulation--a safe and effective procedure in pediatric apheresis therapy. Pediatr Nephrol 2011; 26:127-32. [PMID: 20963447 DOI: 10.1007/s00467-010-1658-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 08/31/2010] [Accepted: 09/03/2010] [Indexed: 11/25/2022]
Abstract
Regional citrate anticoagulation (RCA) has been considered to be a standard component of pediatric apheresis therapy for more than a decade. However, data on dosing recommendations and evaluations of the effectiveness and safety of anticoagulation are rarely found in published reports. The aim of this retrospective analysis was to present our single-center experience with RCA in pediatric apheresis therapy with the aim of developing an operating procedure. Five children aged 7-14 years underwent a total of 72 (range 3-44) therapeutic apheresis sessions with RCA in the form of immunoadsorption therapy (2 patients), low-density lipoprotein (LDL)-apheresis (1 patient), and plasmapheresis (two patients). A 3% citrate solution was used. Citrate flow was started at 4.0% of the blood flow velocity and was adapted to match post-filter ionized calcium levels ≤ 0.30 mmol/l. Once the patient's ionized calcium fell to <1.05 mmol/l, an intravenous 10% calcium gluconate solution was administered. Twenty pediatric apheresis patients who received standard heparinization, matched for age, body surface area, processed plasma volume, and blood flow velocity, were enrolled in the study as a comparison group. No side effects were experienced in 72 apheresis session. The 3% citrate solution had to be reduced gradually during the apheresis session and was infused at a mean of 2.8-3.8% of the blood flow rate. Serum bicarbonate levels before and after the apheresis session with RCA [23.9 (range 18.9-30.1) vs. 26.3 (20.2-33.0) mmol/l, respectively] were significantly different (p=0.013). All patients required intravenous calcium substitution to maintain serum calcium levels within the physiological range. Due to the administration of the 3% citrate solution and calcium, all patients significantly gained weight during the procedure, with a median weight gain of 2.5% (p<0.001). The extra fluid load caused problems in patients with kidney failure. Our regimen with RCA is safe, feasible, and effective in pediatric therapeutic apheresis therapy. For RCA in apheresis, we recommend (1) a citrate (3%) flow of 3.3% of the blood flow, (2) prophylactic intravenous calcium substitution from the beginning, and (3) a more highly concentrated citrate solution in the case of oliguric patients.
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Affiliation(s)
- Martin Kreuzer
- Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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