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Pible J, Bidar F, Chardon N, Cerro V, Ichai C, Monard C, Schneider A, Joannes-Boyau O, Constantin JM, Rimmelé T. Anticoagulation Strategies for Continuous Renal Replacement Therapy in France: A Survey of Practices. Blood Purif 2024:1-8. [PMID: 39348821 DOI: 10.1159/000540553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/21/2024] [Indexed: 10/02/2024]
Abstract
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 involving 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 closer biological monitoring (57%) or to modify the CRRT protocol (61%). Among the participants who did not prescribe RCA as a 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 medical and nursing staff easy access to training may facilitate the understanding and use of RCA as the first-line anticoagulation strategy for CRRT.
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Affiliation(s)
- Justine Pible
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Frank Bidar
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
- EA 7426, Pathophysiology of Injury-Induced Immunosuppression, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Chardon
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Valérie Cerro
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Carole Ichai
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Céline Monard
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Antoine Schneider
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Thoraco-Abdominal, CMC Magellan, CHU Bordeaux, Pessac, France
| | - Jean-Michel Constantin
- Département d'Anesthésie-Réanimation, Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Thomas Rimmelé
- Département d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
- EA 7426, Pathophysiology of Injury-Induced Immunosuppression, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
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Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, Tyagi P, Pattajoshi S, Brar K, Patel PB, Zatakiya R, Chandra S, Govil D. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024; 28:859-865. [PMID: 39360210 PMCID: PMC11443258 DOI: 10.5005/jp-journals-10071-24797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 08/08/2024] [Indexed: 10/04/2024] Open
Abstract
Background Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature. Objective The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life. Methodology It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA. Results A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation. Conclusion Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients. How to cite this article Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, et al. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.
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Affiliation(s)
- Anant V Pachisia
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - G Praveen Kumar
- Department of Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Rahul Harne
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - KN Jagadeesh
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Sweta J Patel
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Divya Pal
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Pooja Tyagi
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Swagat Pattajoshi
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Keerti Brar
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Parimal B Patel
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Ronak Zatakiya
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Subhash Chandra
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta – The Medicity, Gurugram, Haryana, India
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Needleman L, Hughes MS, Fatehi P, Sellmeyer DE. Regional citrate anticoagulation with continuous renal replacement therapy as a cause of hypercalcemia. Arch Osteoporos 2024; 19:78. [PMID: 39180669 DOI: 10.1007/s11657-024-01434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/26/2024] [Indexed: 08/26/2024]
Abstract
CLINICAL RELEVANCE Awareness of the causes of hypercalcemia is essential for timely diagnosis of calcium disorders and optimal treatment. Citrate is commonly used as an anticoagulant during continuous renal replacement therapy (CRRT). Accumulation of citrate in the systemic circulation during CRRT may induce several metabolic disturbances, including total hypercalcemia and ionized hypocalcemia. The aim of the present study is to increase awareness of citrate accumulation and toxicity as a cause of hypercalcemia by relating three cases and reviewing the pathophysiology and clinical implications. OBSERVATIONS We utilized electronic health records to examine the clinical cases and outlined key studies to review the consequences of citrate toxicity and general approaches to management. CONCLUSIONS Citrate toxicity is associated with high mortality. A safe threshold for tolerating hypercalcemia during citrate anticoagulation is not clearly defined, and whether citrate toxicity independently increases mortality has not been resolved. Greater attention to citrate toxicity as a cause of hypercalcemia may lead to earlier detection, help to optimize the management of systemic calcium levels, and foster interest in future clinical studies.
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Affiliation(s)
- Leor Needleman
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA
| | - Michael S Hughes
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA
| | - Pedram Fatehi
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA, 94305, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Deborah E Sellmeyer
- Department of Medicine, Division of Endocrinology, Gerontology and Metabolism, Stanford University, Stanford, CA, 94305, USA.
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Dimski T, Brandenburger T, Vollmer C, Kindgen-Milles D. A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation. BMC Nephrol 2024; 25:218. [PMID: 38982339 PMCID: PMC11234626 DOI: 10.1186/s12882-024-03659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. METHODS This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. RESULTS We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. CONCLUSIONS We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. TRIAL REGISTRATION The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany.
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
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Kunz JV, Hansmann H, Fähndrich M, Pigorsch M, Bethke N, Peters H, Krüger A, Schroeder T, Marcy F, Magomedov A, Müller-Redetzky H, Eckardt KU, Khadzhynov D, Enghard P. Standard vs. carbone dioxide adapted kidney replacement therapy in hypercapnic ARDS patients: a randomized controlled pilot trial (BigBIC). Crit Care 2024; 28:198. [PMID: 38863072 PMCID: PMC11167756 DOI: 10.1186/s13054-024-04979-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Current continuous kidney replacement therapy (CKRT) protocols ignore physiological renal compensation for hypercapnia. This study aimed to explore feasibility, safety, and clinical benefits of pCO2-adapted CKRT for hypercapnic acute respiratory distress syndrome (ARDS) patients with indication for CKRT. METHODS We enrolled mechanically ventilated hypercapnic ARDS patients (pCO2 > 7.33 kPa) receiving regional citrate anticoagulation (RCA) based CKRT in a prospective, randomized-controlled pilot-study across five intensive care units at the Charité-Universitätsmedizin Berlin, Germany. Patients were randomly assigned 1:1 to the control group with bicarbonate targeted to 24 mmol/l or pCO2-adapted-CKRT with target bicarbonate corresponding to physiological renal compensation. Study duration was six days. Primary outcome was bicarbonate after 72 h. Secondary endpoints included safety and clinical endpoints. Endpoints were assessed in all patients receiving treatment. RESULTS From September 2021 to May 2023 40 patients (80% male) were enrolled. 19 patients were randomized to the control group, 21 patients were randomized to pCO2-adapted-CKRT. Five patients were excluded before receiving treatment: three in the control group (consent withdrawal, lack of inclusion criteria fulfillment (n = 2)) and two in the intervention group (lack of inclusion criteria fulfillment, sudden unexpected death) and were therefore not included in the analysis. Median plasma bicarbonate 72 h after randomization was significantly higher in the intervention group (30.70 mmol/l (IQR 29.48; 31.93)) than in the control group (26.40 mmol/l (IQR 25.63; 26.88); p < 0.0001). More patients in the intervention group received lung protective ventilation defined as tidal volume < 8 ml/kg predicted body weight. Thirty-day mortality was 10/16 (63%) in the control group vs. 8/19 (42%) in the intervention group (p = 0.26). CONCLUSION Tailoring CKRT to physiological renal compensation of respiratory acidosis appears feasible and safe with the potential to improve patient care in hypercapnic ARDS. TRIAL REGISTRATION The trial was registered in the German Clinical Trials Register (DRKS00026177) on September 9, 2021 and is now closed.
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Affiliation(s)
- Julius Valentin Kunz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Helena Hansmann
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Mareike Fähndrich
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mareen Pigorsch
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Nicole Bethke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, Vivantes Klinikum Friedrichshain, Berlin, Germany
| | - Harm Peters
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anne Krüger
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Florian Marcy
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Abakar Magomedov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Holger Müller-Redetzky
- Department of Infectious Diseases, Pneumology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Kuratorium for Dialysis and Transplantation (KfH) Renal Unit Berlin-Mitte, Große Hamburger Str. 5-11, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
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Haselwanter P, Scheiner B, Balcar L, Semmler G, Riedl-Wewalka M, Schmid M, Reiberger T, Zauner C, Schneeweiss-Gleixner M. Use of the CytoSorb adsorber in patients with acute-on-chronic liver failure. Sci Rep 2024; 14:11309. [PMID: 38760460 PMCID: PMC11101465 DOI: 10.1038/s41598-024-61658-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
CytoSorb is a hemoadsorptive column used to remove high concentrations of proinflammatory cytokines in septic shock. Data on CytoSorb application in acute-on-chronic liver failure (ACLF) is lacking. This retrospective observational study analyzed 21 ACLF patients admitted to ICUs at the Vienna General Hospital who received CytoSorb adsorber therapy between 2017 and 2023. Median ICU length of stay was 8 days (IQR: 3-13), the ICU survival rate was 23.8% (n = 5). Significant decreases in bilirubin (median peak: 20.7 mg/dL to median post-treatment: 10.8 mg/dL; - 47.8%; p < 0.001), procalcitonin (1.34 to 0.74 pg/mL; - 44.6%; p < 0.001), interleukin-6 (385 to 131 ng/mL; - 66.0%; p = 0.0182)-but also of platelets (72 to 31 G/L; - 56.9%; p = 0.0014) and fibrinogen (230 to 154 mg/dL; - 33.0%; p = 0.0297) were detected. ICU survivors had a trend towards a stronger relative decrease in bilirubin (- 76.1% vs. - 48.2%), procalcitonin (- 90.6% vs. - 23.5%), and IL-6 (- 54.6% vs. - 17.8%) upon CytoSorb treatment. Moreover, no serious CytoSorb-attributed complications were detected. In conclusion, use of CytoSorb adsorber in ACLF patients results in a significant decrease in bilirubin and proinflammatory cytokines, while platelets and fibrinogen were also lowered. Prospective trials are warranted to investigate the impact of CytoSorb on clinical outcomes of ACLF patients with high proinflammatory cytokine levels.
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Affiliation(s)
- Patrick Haselwanter
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernhard Scheiner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Lorenz Balcar
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marlene Riedl-Wewalka
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Monika Schmid
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Reiberger
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Zauner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Mathias Schneeweiss-Gleixner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Tao Z, Feng Y, Wang J, Zhou Y, Yang J. Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis. Blood Purif 2024; 53:436-464. [PMID: 38310853 DOI: 10.1159/000536312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) is one of the most widely used blood purification and organ support methods in the ICU. However, the development process, the current status, hotspots, and future trends of CRRT remain unclear. METHOD The WoSCC database was used to analyze CRRT research evolution and theme trends. VOSviewer was used to construct coauthorship, co-occurrence, co-citation, and network visualizations. CiteSpace is used to detect bursts for co-occurrence items. Several important subtopics were reviewed and discussed in more detail. RESULTS Global publications increased from 56 in 2000 to 398 in 2023, a 710.71% increase. Blood Purification published the most manuscripts, followed by the International Journal of Artificial Organs. The USA, the San Bortolo Hospital, and Bellomo were the most productive and impactful institution, country, and author, respectively. Based on co-occurrence cluster analysis, five clusters emerged: (1) clinical applications and management of CRRT; (2) sepsis and CRRT; (3) CRRT anticoagulant management; (4) CRRT and antibiotic pharmacokinetics and pharmacodynamics; and (5) comparison of CRRT and intermittent hemodialysis. COVID-19, initiation, ECOMO, cefepime, guidelines, cardiogenic shock, biomarker, and outcome were the latest high-frequency keywords or strongest bursts, indicating the emerging frontiers of CRRT. CONCLUSIONS There has been widespread publication and citation of CRRT research in the past 2 decades. We provide an overview of current trends, global collaboration patterns, basic knowledge, research hotspots, and emerging frontiers.
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Affiliation(s)
- ZhongBin Tao
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - YanDong Feng
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - Jie Wang
- Department of Pediatrics, The Second People's Hospital of Gansu Province, Lanzhou, China
| | - YongKang Zhou
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
| | - JunQiang Yang
- Department of Pediatrics, The First Hospital of Lanzhou University, Lanzhou, China
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Xinping Z, Jie H, Zhenya Y, Desheng Z, Xiong Z. Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children. Int J Artif Organs 2024; 47:85-95. [PMID: 38229209 DOI: 10.1177/03913988231223375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT). METHODS This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety. RESULTS The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT. CONCLUSIONS The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.
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Affiliation(s)
- Zhang Xinping
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - He Jie
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Yao Zhenya
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhu Desheng
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhou Xiong
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
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Bai M, Yu Y, Zhao L, Tian X, Zhou M, Jiao J, Liu Y, Li Y, Yue Y, Wei L, Jing R, Li Y, Ma F, Liang Y, Sun S. Regional Citrate Anticoagulation versus No Anticoagulation for CKRT in Patients with Liver Failure with Increased Bleeding Risk. Clin J Am Soc Nephrol 2024; 19:151-160. [PMID: 37990929 PMCID: PMC10861105 DOI: 10.2215/cjn.0000000000000351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients. METHODS Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure. RESULTS Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours. CONCLUSIONS For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .
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Affiliation(s)
- Ming Bai
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Yu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijuan Zhao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Xiujuan Tian
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Meilan Zhou
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Jing Jiao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yajuan Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yuan Yue
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lei Wei
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Rui Jing
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yangping Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Feng Ma
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ying Liang
- Department of Health Statistics, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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10
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Jiao J, Yu Y, Wei S, Tian X, Yang X, Feng S, Li Y, Sun S, Zhang P, Bai M. Heparin anticoagulation versus regional citrate anticoagulation for membrane therapeutic plasma exchange in patients with increased bleeding risk. Ren Fail 2023; 45:2210691. [PMID: 37183868 DOI: 10.1080/0886022x.2023.2210691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Background Heparin anticoagulation (HA) is commonly employed for membrane therapeutic plasma exchange (mTPE). However, for patients with increased bleeding risk, there were controversial opinions on the use of HA versus regional citrate anticoagulation (RCA) for mTPE. Our present study aimed to evaluate the efficacy and safety of HA vs. RCA for mTPE in patients with increased bleeding risk.Methods Patients with increased bleeding risk who underwent mTPE between 2014 and 2021 in our center were screened. Observations of anticoagulation efficacy and safety were used as the study endpoints.Results A total of 108 patients with 368 mTPE sessions were included. Of the included patients, 38 and 70 received HA and RCA mTPE, respectively. There was no significant difference in the clotting of extracorporeal circuits between the HA and RCA groups (4.1% vs. 4.4%, p = 0.605). More bleeding episodes were observed in the HA group compared to the RCA group (16.4% vs. 4.4% mTPE sessions, p < 0.001). The frequency of postoperative transfusion within 24 h (11% vs. 3.4%, p = 0.007) was significantly different in the HA and RCA group. Anticoagulation strategy (HA vs. RCA; OR 5.659, 95%CI 2.266-14.129; p < 0.001), and mean arterial pressure (prior treatment, OR 1.052, 95%CI 1.019-1.086; p = 0.002) were independent risk factors of bleeding episodes. At the end of mTPE treatment, the incidence of metabolic alkalosis (16.7% vs. 54.1%, p = 0.027) and hypocalcemia (41.7% vs. 89.2%, p = 0.001) was significantly different in the HA (n = 5, 12 sessions) and RCA (n = 22, 74 sessions) groups, respectively.Conclusion RCA is as effective as HA for mTPE. However, for patients with increased bleeding risk, RCA is associated with a lower risk of bleeding, compared with HA. With careful monitoring and timely adjustment, RCA most likely is a safe and effective anticoagulation option for mTPE in patients with increased bleeding risk.
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Affiliation(s)
- Jing Jiao
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
- Xi'an Medical University, Xi 'an, Shaanxi, China
| | - Yan Yu
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Suijiao Wei
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
- Xi'an Medical University, Xi 'an, Shaanxi, China
| | - Xiujuan Tian
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiaoxia Yang
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Shidong Feng
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yajuan Li
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Peng Zhang
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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Assefi M, Leurent A, Blanchard F, Quemeneur C, Deransy R, Monsel A, Constantin JM. Impact of increasing post-filter ionized calcium target on filter lifespan in renal replacement therapy with regional citrate anticoagulation: A before-and-after study. J Crit Care 2023; 78:154364. [PMID: 37379797 DOI: 10.1016/j.jcrc.2023.154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Regional citrate anticoagulation (RCA) is the recommended method for anticoagulation in continuous renal replacement therapy (CRRT). However, the optimal post-filter ionized calcium (iCa) target level remains unclear. This study aims to assess the effect of increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L on filter lifespan until clotting during RCA-CRRT. METHODS This before-and-after single-center study included patients who underwent RCA-CRRT sessions without systemic anticoagulation during two periods. The first period included patients with a post-filter iCa target between 0.25 and 0.35 mmol/L, while the second period included those with a target between 0.30 and 0.40 mmol/L. The primary outcome was filter lifespan until clotting. RESULTS A total of 1037 CRRT sessions were analyzed, with 610 sessions in the first period and 427 sessions in the second period. After adjusting for confounding factors, there was no significant difference in filter lifespan until clotting between the two groups (hazard ratio, 1.020 [0.703; 1.481]; p = 0.92). CONCLUSION Increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L during RCA-CRRT does not reduce filter lifespan until clotting and may decrease unnecessary citrate exposure. However, the optimal post-filter iCa target should be individualized according to the patient's clinical and biological status.
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Affiliation(s)
- Mona Assefi
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France.
| | - Alix Leurent
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Florian Blanchard
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Cyril Quemeneur
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Romain Deransy
- Université de Nantes, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Antoine Monsel
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University-INSERM UMRS_959, Immunology-Immunopathology-Immunotherapy (I3), 75013 Paris, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
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Brunoni B, Zadek F, Mulazzani F, Verza G, Marrazzo F, Spina S, Protti A, Fumagalli R, Langer T. Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review. Blood Purif 2023; 52:802-811. [PMID: 37673054 DOI: 10.1159/000531953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/29/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Metformin intoxication causes lactic acidosis by inhibiting Krebs' cycle and oxidative phosphorylation. Continuous renal replacement therapy (CRRT) is recommended for metformin removal in critically ill patients. According to current guidelines, regional citrate anticoagulation (RCA) is the first-line strategy. However, since metformin also inhibits citrate metabolism, a risk of citrate accumulation could be hypothesized. In the present study, we monitored the potential citrate accumulation in metformin-associated lactic acidosis (MALA) patients treated with CRRT and RCA using the physical-chemical approach to acid-base interpretation. METHODS We collected a case series of 3 patients with MALA. Patients were treated with continuous venovenous hemofiltration (CVVH), and RCA was performed with diluted citrate solution. Citrate accumulation was monitored through two methods: the ratio between total and ionized plasma calcium concentrations (T/I calcium ratio) above 2.5 and the strong ion gap (SIG) to identify an increased concentration of unmeasured anions. Lastly, a mathematical model was developed to estimate the expected citrate accumulation during CVVH and RCA. RESULTS All 3 patients showed a resolution of MALA after the treatment with CVVH. The T/I calcium ratio was consistently below 2.5, and SIG decreased, reaching values lower than 6 mEq/L after 48 h of CVVH treatment. According to the mathematical model, the estimated SIG without citrate metabolism should have been around 21 mEq/L due to citrate accumulation. CONCLUSIONS In our clinical management, no signs of citrate accumulation were recorded in MALA patients during treatment with CVVH and RCA. Our data support the safe use of diluted citrate to perform RCA during metformin intoxication.
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Affiliation(s)
- Beatrice Brunoni
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesca Mulazzani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giovanni Verza
- INFN, Sezione di Padova, Padova, Italy
- Dipartimento di Fisica e Astronomia "G. Galilei", Università Degli Studi di Padova, Padova, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Stefano Spina
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
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Thanapongsatorn P, Sinjira T, Kaewdoungtien P, Kusirisin P, Kulvichit W, Sirivongrangson P, Peerapornratana S, Lumlertgul N, Srisawat N. Standard versus no post-filter ionized calcium monitoring in regional citrate anticoagulation for continuous renal replacement therapy (NPC trial). Clin Kidney J 2023; 16:1469-1479. [PMID: 37664560 PMCID: PMC10468745 DOI: 10.1093/ckj/sfad069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 09/05/2023] Open
Abstract
Background Current guidelines recommend monitoring of post-filter ionized calcium (pfCa) when using regional citrate anticoagulation during continuous renal replacement therapy (RCA-CRRT) to determine citrate efficiency for the prevention of filter clotting. However, the reliability of pfCa raises the question of whether routine monitoring is required. Reducing the frequency of pfCa monitoring could potentially reduce costs and workload. Our objective was to test the efficacy and safety of no pfCa monitoring among critically ill patients receiving RCA-CRRT. Methods This study was a non-inferiority randomized controlled trial conducted between January 2021 and October 2021 at King Chulalongkorn Memorial Hospital, Thailand. Critically ill patients who were treated with RCA-CRRT were randomized to receive either standard pfCa monitoring (aiming pfCa level of 0.25-0.35 mmol/L), or no pfCa monitoring, in which a constant rate of citrate infusion was maintained at pre-determined citrate concentrations of 4 mmol/L with blinding of pfCa levels to treating clinicians. The primary outcome was the filter lifespan. Non-inferiority would be demonstrated if the upper limit of the 95% confidence interval (CI) for the difference in filter lifespan between the groups was less than 20 h. Results Fifty patients were randomized to the standard pfCa monitoring group (n = 25) or no pfCa monitoring group (n = 25). The mean filter lifespan was 54 ± 20 h in the standard pfCa monitoring group and 47 ± 23 h in the no pfCa monitoring group (absolute difference 7.1 h; 95% CI -5.3, 19.5, P = .25). When restricting the analysis to circuits reaching the maximum duration of circuit lifespan at 72 h and clotted filters, the filter lifespan was 61 ± 17 h in the standard pfCa group vs 60 ± 19 h in the no pfCa monitoring group (absolute difference 0.9 h; 95% CI -11.5, 13.4, P = .88). Compared with the no pfCa monitoring group, the standard pfCa monitoring group had a significantly higher mean citrate concentrations (4.43 ± 0.32 vs 4 mmol/L, P < .001) and a higher rate of severe hypocalcemia (44% vs 20%, P = .13). No statistical differences were found in filter clotting, citrate accumulation, citrate overload and mortality between the two groups. Conclusions Among critically ill patients receiving RCA-CRRT, no pfCa monitoring by maintaining the citrate concentrations of 4 mmol/L is feasible. Larger randomized controlled trials should be conducted to ensure the efficacy, safety and cost-effectiveness of this strategy. Trial registration ClinicalTrials.gov: NCT04792424 (registered 11 March 2021).
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Affiliation(s)
- Peerapat Thanapongsatorn
- Department of Medicine, Central Chest Institute of Thailand, Nonthaburi, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Tanyapim Sinjira
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyanut Kaewdoungtien
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Prit Kusirisin
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Win Kulvichit
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sadudee Peerapornratana
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nuttha Lumlertgul
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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Liu SY, Xu SY, Yin L, Yang T, Jin K, Zhang QB, Sun F, Tan DY, Xin TY, Chen YG, Zhao XD, Yu XZ, Xu J. Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus. Mil Med Res 2023; 10:23. [PMID: 37248514 DOI: 10.1186/s40779-023-00457-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is widely used for treating critically-ill patients in the emergency department in China. Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT. Regional citrate anticoagulation (RCA) has been shown to potentially be safer and more effective and is now recommended as the preferred anticoagulant method for CRRT. However, there is still a lack of unified standards for RCA management in the world, and there are many problems in using this method in clinical practice. The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues, including the advantages and disadvantages of RCA in CRRT anticoagulation, the principle of RCA, parameter settings for RCA, monitoring of RCA (mainly metabolic acid-base disorders), and special issues during RCA. Based on the latest available research evidence as well as the paneled experts' clinical experience, considering the generalizability, suitability, and potential resource utilization, while also balancing clinical advantages and disadvantages, a total of 16 guideline recommendations were formed from the experts' consensus.
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Affiliation(s)
- Shu-Yuan Liu
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Sheng-Yong Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lu Yin
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen, 518000, China
| | - Ting Yang
- Emergency Department, The First Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Kui Jin
- Emergency Department, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Qiu-Bin Zhang
- Emergency Department, The Second Affiliated Hospital of Hainan Medical College, Haikou, 570100, China
| | - Feng Sun
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ding-Yu Tan
- Emergency Department, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Tian-Yu Xin
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Yu-Guo Chen
- Emergency Department and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, 100005, China.
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Jinan, 100005, China.
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, 100005, China.
| | - Xiao-Dong Zhao
- Emergency Department, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China.
| | - Xue-Zhong Yu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Jun Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Jacobs R, Verbrugghe W, Dams K, Roelant E, Couttenye MM, Devroey D, Jorens P. Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Life (Basel) 2023; 13:life13051198. [PMID: 37240843 DOI: 10.3390/life13051198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. METHODS Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. RESULTS Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110). CONCLUSION regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.
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Affiliation(s)
- Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Walter Verbrugghe
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Karolien Dams
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Marie Madeleine Couttenye
- Department of Nephrology and Hypertension, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
| | - Dirk Devroey
- Deparmtment of Family Medicine and Chronic Care, Faculty of Medicine and Framacy, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
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16
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Pistolesi V, Morabito S, Pota V, Valente F, Di Mario F, Fiaccadori E, Grasselli G, Brienza N, Cantaluppi V, De Rosa S, Fanelli V, Fiorentino M, Marengo M, Romagnoli S. Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:7. [PMID: 37386664 DOI: 10.1186/s44158-023-00091-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 07/01/2023]
Abstract
Renal replacement therapies (RRT) are essential to support critically ill patients with severe acute kidney injury (AKI), providing control of solutes, fluid balance and acid-base status. To maintain the patency of the extracorporeal circuit, minimizing downtime periods and blood losses due to filter clotting, an effective anticoagulation strategy is required.Regional citrate anticoagulation (RCA) has been introduced in clinical practice for continuous RRT (CRRT) in the early 1990s and has had a progressively wider acceptance in parallel to the development of simplified systems and safe protocols. Main guidelines on AKI support the use of RCA as the first line anticoagulation strategy during CRRT in patients without contraindications to citrate and regardless of the patient's bleeding risk.Experts from the SIAARTI-SIN joint commission have prepared this position statement which discusses the use of RCA in different RRT modalities also in combination with other extracorporeal organ support systems. Furthermore, advise is provided on potential limitations to the use of RCA in high-risk patients with particular attention to the need for a rigorous monitoring in complex clinical settings. Finally, the main findings about the prospective of optimization of RRT solutions aimed at preventing electrolyte derangements during RCA are discussed in detail.
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Affiliation(s)
- Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy.
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Fabrizio Valente
- Nephrology and Dialysis Unit, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, ICU Section, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine (DIMET), University of Piemonte Orientale (UPO), AOU "Maggiore Della Carità", Novara, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Fiorentino
- Nephrology Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - Marita Marengo
- Department of Medical Specialist, Nephrology and Dialysis Unit, ASL CN1, Cuneo, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
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17
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Mendibaev MS, Rabotinsky SE. Pharmacological methods for blood stabilization in the extracorporeal circuit (review of literature). MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2023. [DOI: 10.24884/2078-5658-2023-20-1-81-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
We summarize the possible benefits and risks of using various anticoagulants during hemoperfusion. Clotting in the extracorporeal circuit can lead to a decrease in the effectiveness of therapy, additional workload, risk to the patient and economic losses. At the same time, relatively excessive anticoagulation against the background of existing hemostasis disorders can lead to severe hemorrhagic complications, which in turn worsen the prognosis of patients. The article describes the causes of heparin resistance, the main techniques for overcoming it, and provides practical guidelines for anticoagulant therapy during hemoperfusion. It is well known that routine methods of monitoring hemostasis (such as platelet count, activated partial thromboplastin time) are unable to assess the balance of pro/anticoagulants. The authors have proposed a reasonable personalized approach to anticoagulant therapy of extracorporeal blood purification depending on the pathology in patient and thromboelastography (TEG) data, and antithrombin III levels.
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18
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To HHM, Kwan AMC, Leung NYY, Chan WM, Ngai CW, Wong ASK, Tsai PNW, Ma TSK, Yam I, Ng PY, Yap DYH. A prospective study on serum citrate levels and clinical correlations in patients receiving regional citrate anticoagulation. Clin Kidney J 2022; 16:285-292. [PMID: 36755836 PMCID: PMC9900571 DOI: 10.1093/ckj/sfac223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Current ways to diagnose citrate accumulation (CA) in patients receiving regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) are confounded by various clinical factors. Serum citrate measurement emerges as a more direct way to diagnose CA, but its clinical utility and optimal cut-off values remain undefined. This study examined serum citrate kinetics and its diagnostic performance for CA in patients receiving RCA CRRT. Methods A multicentre prospective study was carried out in two tertiary referral centre intensive care units in Hong Kong with serum citrate levels measured at baseline and 2, 6, 12, 24, 36, 48 and 72 h after initiation of RCA CRRT and their relationships with the development of CA. Results Among the 133 patients analysed, 18 patients (13.5%) developed CA. The serum citrate levels at baseline and 2, 6 and 12 h after initiation of RCA CRRT in patients who had CA were significantly higher than the non-CA group (P < .001 for all). The CA group also had higher serum citrate levels than the non-CA group {median 0.93 mmol/L [interquartile range (IQR) 0.81-1.16) versus 0.37 mmol/L (IQR 0.26-0.57), P < .001}. Using a cut-off of 0.85 mmol/L, the serum citrate level had a sensitivity of 0.77 and a specificity 0.96 for the diagnosis of CA [area under the receiver operating characteristics curve (AUROC) 0.90, P < .001]. The 2-h and 6-h serum citrate levels had good discriminatory abilities for predicting subsequent development of CA (AUROC 0.86 and 0.83 for 2-h and 6-h citrate levels using cut-off values of 0.34 and 0.63 mmol/L, respectively; P < .001). Conclusion Serum citrate levels were significantly higher in patients with CA compared with patients without CA. Serum citrate levels showed good performance in diagnosing and predicting the development of CA.
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Affiliation(s)
- Harmony H M To
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Arthur M C Kwan
- Department of Anaesthesia and Intensive care, Tuen Mun Hospital, Hong Kong
| | | | - W M Chan
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - C W Ngai
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | | | - Polly N W Tsai
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Tammy S K Ma
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Irene Yam
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong
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19
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He J, Xiao Z, Zhou X, Cao J, Kang X, Zhang X. Comparison of different modalities of continuous renal replacement therapy with regional sodium citrate anticoagulation in paediatric patients. Int J Artif Organs 2022; 45:997-1005. [PMID: 35903018 DOI: 10.1177/03913988221115447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the efficacy and safety of continuous renal replacement therapy (CRRT) modalities with regional sodium citrate anticoagulation (RCA) in children. METHODS This retrospective study was conducted at the paediatric intensive care unit of Hunan Children's Hospital in China. Medical records of paediatric patients hospitalised for RCA-CRRT between April 2017 and March 2021 were reviewed. Patients received continuous venovenous haemodialysis, continuous venovenous haemofiltration (CVVH), or continuous venovenous haemodiafiltration (CVVHDF). RESULTS Patients on continuous venovenous haemodialysis (n = 2) were excluded because of their small sample size. The remaining participants were divided into CVVH and CVVHDF groups; 80 patients received CRRT, with 40 and 62 sessions in the CVVH and CVVHDF groups, respectively. The filtre lifespan was longer in the CVVHDF group than in the CVVH group (median value [interquartile range]; 47 [15] hours vs. 35 [17.5] hours; p = 0.029). Compared with the CVVHDF group, the hazard ratio for filtre lifespan in the CVVH group was 3.023 (95% confidence interval 1.820-5.023, p < 0.001). There were no significant differences in ionised calcium levels of the circuits between the two groups at different time points (p < 0.05). Metabolic alkalosis, hyperlactataemia, hypocalcaemia, and hypercalcaemia occurred in both groups, with metabolic alkalosis being the most common complication. No patients in either group experienced sodium citrate accumulation or hypernatraemia. Inter-group differences in the incidence of these complications were not statistically significant (p > 0.05). CONCLUSIONS Our results suggest that CVVHDF is a better option for RCA-CRRT than CVVH.
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Affiliation(s)
- Jie He
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhenghui Xiao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiong Zhou
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Jianshe Cao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiayan Kang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xinping Zhang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
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20
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Wang M, Ma Y, Du L, Tang H, Bai L. Association between longer duration of citrate accumulation and 90-day mortality of acute-on-chronic liver failure. Crit Care 2021; 25:387. [PMID: 34763710 PMCID: PMC8588580 DOI: 10.1186/s13054-021-03819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/08/2021] [Indexed: 02/08/2023] Open
Affiliation(s)
- Ming Wang
- Center of Infectious Diseases, West China Hospital of Sichuan University, No. 37 GuoXue Xiang, Wuhou District, Chengdu, 610041, China
| | - Yuanji Ma
- Center of Infectious Diseases, West China Hospital of Sichuan University, No. 37 GuoXue Xiang, Wuhou District, Chengdu, 610041, China
| | - Lingyao Du
- Center of Infectious Diseases, West China Hospital of Sichuan University, No. 37 GuoXue Xiang, Wuhou District, Chengdu, 610041, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, No. 37 GuoXue Xiang, Wuhou District, Chengdu, 610041, China.
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University, No. 37 GuoXue Xiang, Wuhou District, Chengdu, 610041, China.
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21
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Klingele M, Baerens L. Impact of Renal Replacement Therapy on Mortality in Critically Ill Patients-The Nephrologist's View within an Interdisciplinary Intensive Care Team. J Clin Med 2021; 10:jcm10153379. [PMID: 34362161 PMCID: PMC8348049 DOI: 10.3390/jcm10153379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/21/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.
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Affiliation(s)
- Matthias Klingele
- Department of Internal Medicine, Nephrology and Hypertension, Saarland University Medical Centre, 66424 Homburg/Saar, Germany;
- Department of Nephrology, Hochtaunuskliniken, 61352 Bad Homburg, Germany
- Correspondence: ; Tel.: +49-6081-107-4326; Fax: +49-6081-107-104326
| | - Lea Baerens
- Department of Internal Medicine, Nephrology and Hypertension, Saarland University Medical Centre, 66424 Homburg/Saar, Germany;
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22
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Chen H, Ma Y, Hong N, Wang H, Su L, Liu C, He J, Jiang H, Long Y, Zhu W. Early warning of citric acid overdose and timely adjustment of regional citrate anticoagulation based on machine learning methods. BMC Med Inform Decis Mak 2021; 21:126. [PMID: 34330247 PMCID: PMC8323216 DOI: 10.1186/s12911-021-01489-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/07/2021] [Indexed: 12/29/2022] Open
Abstract
Background Regional citrate anticoagulation (RCA) is an important local anticoagulation method during bedside continuous renal replacement therapy. To improve patient safety and achieve computer assisted dose monitoring and control, we took intensive care units patients into cohort and aiming at developing a data-driven machine learning model to give early warning of citric acid overdose and provide adjustment suggestions on citrate pumping rate and 10% calcium gluconate input rate for RCA treatment. Methods Patient age, gender, pumped citric acid dose value, 5% NaHCO3 solvent, replacement fluid solvent, body temperature value, and replacement fluid PH value as clinical features, models attempted to classify patients who received regional citrate anticoagulation into correct outcome category. Four models, Adaboost, XGBoost, support vector machine (SVM) and shallow neural network, were compared on the performance of predicting outcomes. Prediction results were evaluated using accuracy, precision, recall and F1-score. Results For classifying patients at the early stages of citric acid treatment, the accuracy of neutral networks model is higher than Adaboost, XGBoost and SVM, the F1-score of shallow neutral networks (90.77%) is overall outperformed than other models (88.40%, 82.17% and 88.96% for Adaboost, XGBoost and SVM). Extended experiment and validation were further conducted using the MIMIC-III database, the F1-scores for shallow neutral networks, Adaboost, XGBoost and SVM are 80.00%, 80.46%, 80.37% and 78.90%, the AUCs are 0.8638, 0.8086, 0.8466 and 0.7919 respectively. Conclusion The results of this study demonstrated the feasibility and performance of machine learning methods for monitoring and adjusting local regional citrate anticoagulation, and further provide decision-making recommendations to clinicians point-of-care. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01489-8.
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Affiliation(s)
- Huan Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yingying Ma
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Na Hong
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Hao Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chun Liu
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Jie He
- Digital Health China Technologies Co., Ltd., Beijing, 100080, China
| | - Huizhen Jiang
- Department of General Internal Medicine, Department of Information Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Weiguo Zhu
- Department of Primary Care and Family Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China. .,Department of General Internal Medicine, Department of Information Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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23
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Warnar C, Faber E, Katinakis PA, Schermer T, Spronk PE. Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy. J Clin Monit Comput 2021; 36:871-877. [PMID: 33991270 DOI: 10.1007/s10877-021-00719-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.
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Affiliation(s)
- C Warnar
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - E Faber
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - P A Katinakis
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - T Schermer
- Department of Epidemiology, Gelre Hospitals, Apeldoorn , The Netherlands
| | - P E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.,Expertise Center for Intensive Care Rehabilitation Apeldoorn - ExpIRA, Gelre Hospitals, Apeldoorn , The Netherlands
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Xin X, Tang J, Jia HM, Zhang TE, Zheng Y, Huang LF, Ding Q, Li JC, Guo SY, Li WX. Development of a Multivariable Prediction Model for Citrate Accumulation in Liver Transplant Patients Undergoing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2021; 51:111-121. [PMID: 33951630 DOI: 10.1159/000513947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with impaired citrate metabolism may experience citrate accumulation (CA), which causes life-threatening metabolic acidosis and hypocalcemia. CA poses a challenge for clinicians when deciding on the use of regional citrate anticoagulation (RCA) for patients with liver dysfunction. This study aimed to develop a prediction model integrating multiple clinical variables to assess the risk of CA in liver transplant patients. METHODS This single-center prospective cohort study included postoperative liver transplant patients who underwent continuous renal replacement therapy (CRRT) with RCA. The study end point was CA. A prediction model was developed using a generalized linear mixed-effect model based on the Akaike information criterion. The predictive values were assessed using the receiver operating characteristic curve and bootstrap resampling (times = 500) to estimate the area under the curve (AUC) and the corresponding 95% confidence interval (CI). A nomogram was used to visualize the model. RESULTS This study included 32 patients who underwent 133 CRRT sessions with RCA. CA occurred in 46 CRRT sessions. The model included lactate, norepinephrine >0.1 μg/kg/min, alanine aminotransferase, total bilirubin, and standard bicarbonate, which were tested before starting each CRRT session and body mass index, diabetes mellitus, and chronic kidney disease as predictors. The AUC of the model was 0.867 (95% CI 0.786-0.921), which was significantly higher than that of the single predictor (p < 0.05). A nomogram visualized the prediction model. CONCLUSIONS The prediction model integrating multiple clinical variables showed a good predictive value for CA. A nomogram visualized the model for easy application in clinical practice.
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Affiliation(s)
- Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Tang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui-Miao Jia
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tian-En Zhang
- Department of Health Science, Gettysburg College, Gettysburg, Pennsylvania, USA
| | - Yue Zheng
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li-Feng Huang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qi Ding
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jun-Cong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu-Yan Guo
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wen-Xiong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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25
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Li L, Bai M, Zhang W, Zhao L, Yu Y, Sun S. Regional citrate anticoagulation versus low molecular weight heparin for CRRT in hyperlactatemia patients: A retrospective case-control study. Int J Artif Organs 2021; 45:343-350. [PMID: 33784842 DOI: 10.1177/03913988211003586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION There were controversial opinions on the use of regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) for continuous renal replacement therapy (CRRT) in hyperlactatemia patients, which was considered as one of the contraindications of citrate. The aim of our present study is to evaluate the efficacy and safety of RCA versus LMWH for CRRT in hyperlactatemia patients. METHODS Adult patients with hyperlactatemia who underwent RCA or LMWH CRRT in our center between January 2014 and March 2018 were retrospectively recruited. Filter lifespan, ultrafiltration, purification, bleeding, citrate accumulation, filter clot, and the infusion of blood production were evaluated as endpoints. RESULTS Of the 127 patients included in the original cohort, 81 and 46 accepted RCA and LMWH CRRT, respectively. The filter lifespan was significantly prolonged in the RCA group compared to the LMWH group (44.25 h [2 -83] vs. 24 h [4 -67], p < 0.001). The accumulated filter survival proportions were significantly improved in the RCA group compared to the LMWH group in the original cohort (p < 0.001) as well as the matched group (p < 0.001). The filters clotted more frequently in the LMWH group than in the RCA group in both of the original (52.2% vs 26.8%, p = 0.001) and matched cohort (58.6% vs 19.4%, p = 0.001). The bleeding complication was significantly reduced in the RCA group than in the LMWH group in the matched cohort (28.6% vs 4.5%, p = 0.04). CONCLUSION In critically ill patients with hyperlactatemia requiring CRRT, RCA is superior to LMWH in terms of filter lifespan and bleeding risk without significantly increased risk of citrate accumulation and citrate related metabolic complications. RCA most likely is a safe and effective anticoagulation method for CRRT in patients with hyperlactatemia.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
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26
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Li L, Bai M, Yu Y, Li Y, Zhao L, Sun S. Regional citrate anticoagulation vs no-anticoagulation for CRRT in hyperlactatemia patients with increased bleeding risk: A retrospective cohort study. Semin Dial 2020; 34:209-217. [PMID: 33090579 DOI: 10.1111/sdi.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/08/2020] [Accepted: 09/12/2020] [Indexed: 11/26/2022]
Abstract
There are controversial opinions on the use of regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) in hyperlactatemia patients with increased bleeding risk. Patients with hyperlactatemia and increased bleeding risk who accepted RCA or no-anticoagulation CRRT in our center were retrospectively included. Eighty patients who underwent RCA-CRRT and 47 patients received no-anticoagulation CRRT were included. Filter lifespan was significantly longer in the RCA group than the no-anticoagulation group (44.5 hours [2-89] vs 24.5 hours [1.5-70], P < .001). The adjusted results demonstrated that patients in the no-anticoagulant group had significantly higher risk of filter failure (HR = 4.765, 95% CI 2.703-8.4, P < .001). Bleeding episodes occurred in 19 (24.1%) and 22 (46.8%) patients in the RCA and no-anticoagulation group, respectively (P = .012). The overall citrate accumulation (CA) rate was 5% in the RCA group. Patient mortality was associated with the comorbidity of hypertension, increased serum lactate level, and increased SOFA score. After matching, the filter lifespan was significantly longer in the RCA group than the no-anticoagulation group. With careful monitoring and timely adjustment, RCA most likely was safe and effective for CRRT in hyperlactatemia patients with increased bleeding risk.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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Yu Y, Bai M, Wei Z, Zhao L, Li Y, Ma F, Sun S. Regional citrate anticoagulation versus low molecular weight heparin anticoagulation for continuous venovenous hemofiltration in patients with severe hypercalcemia: a retrospective cohort study. Ren Fail 2020; 42:748-758. [PMID: 32718221 PMCID: PMC7470037 DOI: 10.1080/0886022x.2020.1795879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose We conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus those of low molecular weight heparin (LMWH) anticoagulation for CVVH in severe hypercalcemia patients. Methods Between January 2014 and May 2019, 33 severe hypercalcemia patients underwent CVVH. Patients were divided into the RCA and LMWH groups. Calcium-free replacement solution was used. Serum total calcium reduction rate (RRSeCa), filter lifespan, bleeding, totCa/ionCa ratio, citrate accumulation, and catheter occlusion were evaluated as outcomes. Results RCA and LMWH were employed for CVVH in 14 and 43 filters, respectively. RRSeCa was not significantly different between the LMWH and RCA groups (p = .320), but RCA-CVVH was more effective in reducing ionized calcium at half of the time points (p < .05). RCA significantly prolonged the median filter lifespan (>72 h vs. 24.0 h [IQR, 15.0–26.0], p = .012). The incidence of filter failure was 55.8% (24/43) in the LMWH group and 21.4% (3/14) in the RCA group (p = .033). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (p = .043, 95% CI 0.059–0.957, HR = 0.238). No citrate accumulation or bleeding episodes were observed in the RCA-CVVH group. Seven bleeding episodes (7/43, 16.3%) occurred in the LMWH-CVVH group. Conclusions In patients with severe hypercalcemia who underwent CVVH, RCA more effectively decreased calcium levels and had a superior filter lifespan and no obvious adverse events compared with LMWH. Further prospective, randomized, controlled studies are warranted to obtain robust evidence.
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Affiliation(s)
- Yan Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Zhang Wei
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Shaanxi, China
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Boer W, van Tornout M, Solmi F, Willaert X, Schetz M, Oudemans-van Straaten H. Determinants of Total/ionized Calcium in patients undergoing citrate CVVH: A retrospective observational study. J Crit Care 2020; 59:16-22. [PMID: 32485438 DOI: 10.1016/j.jcrc.2020.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/11/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To identify potential determinants of the Total/ionized Ca ratio (T/iCa), a marker of citrate accumulation. MATERIALS AND METHODS Single-center retrospective observational study evaluating citrate dose, citrate target, albumin, phosphate, pH, lactate, and APACHE II score as potential determinants. Linear mixed models (LMM) using citrate dose and citrate target were developed describing associations with T/iCa. RESULTS From a dataset of 471 samples in 103 patients, an LMM in 379 complete samples (95 patients) sets revealed that citrate dose, pH, phosphate, albumin and APACHE were interactively related to T/iCa. A rising citrate dose was associated with a higher increase in T/iCa when phosphate was high, and less when phosphate was low. A rising albumin was associated with a higher increase in T/iCa when APACHE was high and phosphate was low and less when APACHE was low and phosphate high. In case of acidosis, a rising lactate was associated with a higher increase in T/iCa. In the LMM using citrate target, citrate target and pH were the main independent predictors of T/iCa with albumin, phosphate and APACHE score as modifiers. CONCLUSIONS Besides citrate dose, a high pH and high phosphate, albumin and APACHE are also associated with a rising T/iCa.
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Affiliation(s)
- Willem Boer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Mathias van Tornout
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Francesca Solmi
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Hasselt, Belgium
| | - Xavier Willaert
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Miet Schetz
- Department of Laboratory and Intensive Care Medicine, Catholic University Leuven, Belgium
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Yu Y, Bai M, Ma F, Zhang W, Li Y, Zhao L, Li L, Zhou M, Li L, Sun S. Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study. PLoS One 2020; 15:e0232516. [PMID: 32369523 PMCID: PMC7199954 DOI: 10.1371/journal.pone.0232516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 04/16/2020] [Indexed: 01/01/2023] Open
Abstract
Objective There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients. Methods The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes. Results In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2–47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26–0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups. Conclusions In LF patients with increased bleeding risk who underwent CVVH, RCA could prolong the filter lifespan and be safely used with careful blood gas monitoring and citrate dose adjusting. Further prospective, randomized, control studies are warranted to obtain robust evidences.
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Affiliation(s)
- Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Li Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Meilan Zhou
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
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Zatorski P, Abokhouskaya N, Łącki P, Kołacz M, Trzebicki J. Ionized calcium measurements during continuous renal replacement therapy with regional citrate anticoagulation. Clin Chem Lab Med 2020; 59:e107-e109. [PMID: 33554572 DOI: 10.1515/cclm-2020-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/12/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Paweł Zatorski
- I Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Nadzeya Abokhouskaya
- I Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Łącki
- I Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Kołacz
- I Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Trzebicki
- I Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
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Khadzhynov D, Deissler J, Bobonov O, Schelter C, Peters H, Kindgen-Milles D, Budde K, Lehner LJ, Halleck F, Staeck O, Eckardt KU, Slowinski T. Intensive monitoring of post filter ionized calcium concentrations during CVVHD with regional citrate anticoagulation: A retrospective study. J Crit Care 2020; 58:1-5. [PMID: 32244094 DOI: 10.1016/j.jcrc.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of the present study was to assess the predictive value of post-filter ionized calcium (pfCa) levels for filter-clotting during continuous veno-venous hemodialysis (CVVHD) with regional citrate anticoagulation (RCA). METHODS Retrospective analysis of a database derived from 6 intensive care units (ICU) at a university hospital. During the 3-year period 1070 patients were treated with RCA-CVVHD with a citrate starting dose of 4 mmol/L blood and a target-range for pfCa of 0.25-0.35 mmol/L. RESULTS The pfCa concentrations at RCA-CVVHD initiation were within the target range in 69.7% of patients. Within 12 h the fraction of patients with pfCa above target-range decreased significantly from 13.1% to 7.8% (p < .001). There was no significant difference in filter survival between patients with a pfCa initially below, within, or above the target-range (83.7%, 89.5% and 90.4%; p = .228) and no significant correlation between the last pfCa and the incidence of filter clotting (rho 0.018, p = .572 and -0.054, p = .104; respectively). CONCLUSIONS CVVHD with a citrate starting dose of 4 mmol/L blood resulted in a pfCa within target in the majority of patients. The observation that pfCa was not associated with the incidence of circuit clotting suggests that less frequent measurements of pfCA might be safe.
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Affiliation(s)
- Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Jonas Deissler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Otajon Bobonov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Christin Schelter
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Harm Peters
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine-University, Germany.
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Oliver Staeck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Torsten Slowinski
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
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Honore PM, Mugisha A, David C, Attou R, Redant S, Gallerani A, De Bels D. In severe liver disease, citrate can be used safely: the question remains-by which mechanism. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:63. [PMID: 32093726 PMCID: PMC7038605 DOI: 10.1186/s13054-020-2801-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Aurore Mugisha
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Cristina David
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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Sık G, Demirbuga A, Annayev A, Citak A. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children. Int J Artif Organs 2019; 43:234-241. [PMID: 31856634 DOI: 10.1177/0391398819893382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. METHODS A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydınlar University School of Medicine. RESULTS From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40-70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75-53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5-2.38) with heparin and 0.8 units (interquartile range, 0.3-2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. CONCLUSION Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.
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Affiliation(s)
- Guntulu Sık
- Department of Pediatric Intensive Care, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Asuman Demirbuga
- Department of Pediatric Intensive Care, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Agageldi Annayev
- Department of Pediatric Intensive Care, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Agop Citak
- Department of Pediatric Intensive Care, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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Gao J, Wang F, Wang Y, Jin D, Tang L, Pan K. A mode of CVVH with regional citrate anticoagulation compared to no anticoagulation for acute kidney injury patients at high risk of bleeding. Sci Rep 2019; 9:6607. [PMID: 31036927 PMCID: PMC6488647 DOI: 10.1038/s41598-019-42916-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/10/2019] [Indexed: 12/21/2022] Open
Abstract
The study was designed to assess a practical mode of postdilution continuous venovenous hemofiltration (CVVH) with regional citrate anticoagulation (RCA) using a calcium-containing replacement solution, and to compare it with a CVVH mode with no anticoagulation (NA). Both methods were employed in our center for acute kidney injury (AKI) patients at high risk of bleeding. Fifty-six patients were equally allocated into the RCA-CVVH group and the NA-CVVH group. The study displayed no significant differences between groups involving baseline characteristics, severity level, blood gas analysis, hepatic/renal/coagulative functions, electrolytes, hemoglobin concentration, and platelet counts before or after continuous renal replacement therapy (CRRT). Compared to the NA-CVVH group, the RCA-CVVH group had a lower level of transfused packed red blood cells and platelet as well as a longer filter lifespan. The result showed no substantial differences between groups in terms of the mean supporting time and cost involving CRRT per person, the length of ICU and hospital stays, and the ICU survival. Homeostasis was basically preserved at a target range during the RCA post-CVVH procedure. Serious complications did not arise during the RCA process. RCA postdilutional CVVH is a safe and effective mode for application in AKI patients with a high risk of bleeding, and it can extend the filter lifespan and decrease blood loss, compared with the NA mode for CRRT. Further studies are needed to evaluate this mode for CRRT. (Retrospective Registration number ChiCTR1800016462, Registration date 2/6/2018)
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Affiliation(s)
- Jianping Gao
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Feng Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Yonggang Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Dan Jin
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Liping Tang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Konghan Pan
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
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35
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Renal replacement therapy: a practical update. Can J Anaesth 2019; 66:593-604. [PMID: 30725343 DOI: 10.1007/s12630-019-01306-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (< 25 mL·kg-1·hr-1) vs high (> 40 mL·kg-1·hr-1) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.
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Zhang W, Bai M, Yu Y, Li L, Zhao L, Sun S, Chen X. Safety and efficacy of regional citrate anticoagulation for continuous renal replacement therapy in liver failure patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:22. [PMID: 30678706 PMCID: PMC6345001 DOI: 10.1186/s13054-019-2317-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/10/2019] [Indexed: 12/19/2022]
Abstract
Background Regional citrate anticoagulation (RCA) is a widely used strategy for continuous renal replacement therapy (CRRT). Most of the current guidelines recommend liver failure as one of the contraindications for citrate anticoagulation. However, some studies suggested that the use of citrate for CRRT in liver failure patients did not increase the risk of citrate-related complications. The purpose of this systematic review is to summarize the current evidences on the safety and efficacy of RCA for CRRT in liver failure patients. Methods We performed a comprehensive search on PubMed, Embase, and the Cochrane Library databases from the inception to March 1, 2018. Studies enrolled adult (age > 18 years) patients with various levels of liver dysfunction underwent RCA-CRRT were included in this systematic review. Results After the study screening, 10 observational studies with 1241 liver dysfunction patients were included in this systematic review. The pooled rate of citrate accumulation and bleeding was 12% [3%, 22%] and 5% [2%, 8%], respectively. Compared with the baseline data, the serum pH, bicarbonate, and base excess (BE), the rate of metabolic alkalosis, the serum ionized calcium (ionCa) and total calcium (totCa) level, and the ratio of total calcium/ionized calcium (totCa/ionCa) significantly increased at the end of observation. However, no significant increase was observed in serum citrate (MD − 65.82 [− 194.19, 62.55]), lactate (MD 0.49 [− 0.27, 1.26]) and total bilirubin concentration (MD 0.79 [− 0.70, 2.29]) at the end of CRRT. Compared with non-liver failure patients, the live failure patients showed no significant difference in the pH (MD − 0.04 [− 0.13, 0.05]), serum lactate level (MD 0.69 [− 0.26, 1.64]), and totCa/ionCa ratio (MD 0.03 [− 0.12, 0.18]) during CRRT. The median of mean filter lifespan was 55.9 h, with a range from 22.7 to 72 h. Conclusions Regional citrate anticoagulation seems to be a safe anticoagulation method in liver failure patients underwent CRRT and could yield a favorable filter lifespan. Closely monitoring the acid base status and electrolyte balance may be more necessary during RCA-CRRT in patients with liver failure. Electronic supplementary material The online version of this article (10.1186/s13054-019-2317-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wei Zhang
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China.,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, 28th Fuxing Road, Beijing, 100853, China
| | - Ming Bai
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China.
| | - Yan Yu
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China
| | - Lu Li
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China
| | - Lijuan Zhao
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China
| | - Shiren Sun
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China.
| | - Xiangmei Chen
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China. .,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, 28th Fuxing Road, Beijing, 100853, China.
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Ma Y, Xu Y, Chen F, Wang Y, Bai L, Tang H. Good Tolerance of Citrate Accumulation due to Plasma Exchange among Patients with Acute-on-Chronic Liver Failure: A Prospective, Observational Study. Can J Gastroenterol Hepatol 2018; 2018:4909742. [PMID: 29850456 PMCID: PMC5932514 DOI: 10.1155/2018/4909742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/07/2018] [Accepted: 02/26/2018] [Indexed: 02/05/2023] Open
Abstract
Aim To assess the tolerance of citrate accumulation due to plasma exchange (PE) among patients with acute-on-chronic liver failure (ACLF). Methods A prospective, observational study was conducted among patients with ACLF who received heparin anticoagulation during PE-centered therapy without filtration and dialysis. Citrate accumulation was defined as the value of total calcium (Catot) to ionized calcium (Caion) ratio (Catot/Caion) greater than or equal to 2.5 (Catot/Caion ≥ 2.5). Results Fifty-four patients were enrolled. The mean age and MELD score were 50.0 ± 11.3 years old and 25 ± 7, respectively. Thirty-three patients had liver cirrhosis. The total 3-month survival rate was 57.4% (31/54). The mean Catot/Caion at the time before PE was 2.05 ± 0.14. Catot/Caion ≥ 2.5 occurred in 100.0% (54/54) and 29.6% (16/54) of patients with mean Catot/Caion of 4.34 ± 1.52 and 2.36 ± 0.32 immediately after PE and 1 hour after PE, respectively, and these levels were much higher than those before PE (p < 0.01). However, all values returned to lower than 2.5 by the next morning with no difference from those before PE (2.10 ± 0.14 versus 2.05 ± 0.14, p > 0.05). Hypocalcemia (ionized calcium) and mild alkalosis were the main metabolic alterations. No symptoms associated with hypocalcemia occurred. Conclusions Citrate accumulation is well tolerated by patients with ACLF who receive PE-centered therapy without filtration and dialysis. This study is regeristed with ChiCTR-OOC-17013618.
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Affiliation(s)
- Yuanji Ma
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Yan Xu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Fang Chen
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Ying Wang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
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[Extracorporeal renal replacement therapy in acute kidney injury : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:370-376. [PMID: 29546449 DOI: 10.1007/s00063-018-0418-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/27/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in intensive care unit (ICU) patients. The incidence of AKI in ICU patients exceeds 50% and the associated morbidity and mortality rates increase with severity of AKI. In addition, long-term consequences of AKI are underestimated and several studies show impaired long-term outcome after AKI. In about 5-25% of ICU patients with AKI renal replacement therapy (RRT) is required. OBJECTIVES To assist in indication, timing, modality and application of renal replacement therapy of adult patients, current recommendations from the renal sections of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations stated in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, recommendations from the 17th Acute Disease Quality Initiative (ADQI) Consensus Group, the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) and the expert knowledge and clinical experience of the authors. RESULTS Today, different treatment modalities for RRT are available. Although continuous RRT and intermittent dialysis therapy as well as continuous dialysis therapy have comparable outcomes, differences exist with respect to practical application as well as health-economic aspects. Individualized risk stratification might be helpful to choose the right time to start and the right treatment modality for patients.
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Hill S, Creighton E, Walter E. The safety of regional citrate anticoagulation in renal replacement therapy. J Intensive Care Soc 2018; 19:86. [PMID: 29456612 DOI: 10.1177/1751143717735749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Simon Hill
- Royal Surrey County Hospital, Guildford, UK
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40
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Ma YJ, Chen F, Xu Y, Bai L, Tang H. Application of regional citrate anticoagulation during plasma adsorption and plasma exchange for patients with liver failure at high risk of bleeding. Shijie Huaren Xiaohua Zazhi 2018; 26:165-173. [DOI: 10.11569/wcjd.v26.i3.165] [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] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the feasibility and safety of regional citrate anticoagulation (RCA) during plasma adsorption (PA) plus plasma exchange (PE) therapy for patients with liver failure at high risk of bleeding.
METHODS This was a retrospective study conducted at the Center of Infectious Diseases, West China Hospital of Sichuan University from October 2016 to July 2017. The clinical data of patients with liver failure at high risk of bleeding who received RCA during PA plus PE therapy were collected. The therapeutic effects, citrate accumulation, electrolytes, and acid-base changes were retrospectively analyzed. Citrate accumulation was defined as the total calcium (Catot) to ionized calcium (Caion) ratio (Catot/Caion) ≥ 2.5.
RESULTS Of the seven patients included, two survived and five died. Twenty four sessions of RCA for PA plus PE therapy were accomplished. The mean Caionin vitro during PA therapy was 0.28 mmol/L ± 0.09 mmol/L. Citrate accumulation occurred in 45.8% (11/24) of sessions during PA therapy and in all the sessions at the end of PE therapy. Although citrate accumulation still occurred in 41.7% (10/24) of sessions 2 h after PE therapy, it had been decreased obviously when compared with that at the end of PE therapy (P < 0.01) and it was not present by the next morning. No new bleeding occurred and the original bleeding did not deteriorate during and after PA plus PE therapy. The main side effects were alkalosis and transient low level of Caion and high level of Catot.
CONCLUSION Patients with liver failure still have certain ability to metabolize citrate and tolerate citrate accumulation. RCA may be feasible and safe in the PA plus PE therapy for patients with liver failure.
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Affiliation(s)
- Yuan-Ji Ma
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Fang Chen
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yan Xu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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Xie J, Dong W, Liu R, Wang Y, Li Y. Research on the hepatotoxicity mechanism of citrate-modified silver nanoparticles based on metabolomics and proteomics. Nanotoxicology 2017; 12:18-31. [DOI: 10.1080/17435390.2017.1415389] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jiabin Xie
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, PR China
| | - Wenying Dong
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, PR China
| | - Rui Liu
- School of Chinese Materia Medica, Shanxi University of Traditional Chinese Medicine, Shanxi, PR China
| | - Yuming Wang
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, PR China
| | - Yubo Li
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, PR China
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Schneider AG, Journois D, Rimmelé T. Complications of regional citrate anticoagulation: accumulation or overload? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:281. [PMID: 29151020 PMCID: PMC5694623 DOI: 10.1186/s13054-017-1880-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
Regional citrate anticoagulation (RCA) is now recommended over systemic heparin for continuous renal replacement therapy in patients without contraindications. Its use is likely to increase throughout the world. However, in the absence of citrate blood level monitoring, the diagnosis of citrate accumulation, the most feared complication of RCA, remains relatively complex. It is therefore commonly mistaken with other conditions. This review aims at providing clarifications on RCA-associated acid-base disturbances and their management at the bedside. In particular, the authors wish to propose a clear distinction between citrate accumulation and net citrate overload.
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Affiliation(s)
- Antoine G Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), 46 avenue du Bugnon, 1011, Lausanne, Switzerland. .,Université de Lausanne, UNIL, Lausanne, Switzerland.
| | - Didier Journois
- Anesthesiology and Intensive Care Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, René Descartes University, Paris, France
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7426 (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux) "Pathophysiology of Injury-induced Immunosupression - PI3", Joint Research Unit, Edouard Herriot Hospital, Lyon, France
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Hyperlactatemia, Lactate Kinetics and Prediction of Citrate Accumulation in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy With Regional Citrate Anticoagulation. Crit Care Med 2017; 45:e941-e946. [PMID: 28538441 DOI: 10.1097/ccm.0000000000002501] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Citrate accumulation is a major complication of regional citrate anticoagulation during continuous renal replacement therapy. We studied the prediction of citrate accumulation during continuous veno-venous hemodialysis with regional citrate anticoagulation by initial lactate concentrations and lactate kinetics. DESIGN A retrospective follow-up analysis from a cohort of critically ill patients. SETTING Mixed medical-surgical ICUs at a university hospital. PATIENTS All adult patients with acute kidney injury and treated with regional citrate anticoagulation-continuous veno-venous hemodialysis during a 3-year period (n = 1,070) were included in this retrospective study and screened for metabolic signs of citrate accumulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The frequency of citrate accumulation during the first 48 hours of therapy was 2.26%. In patients with initial normal lactate (< 2.2 mmol/L), elevated lactate (≥ 2.2 to < 4 mmol/L), or severe hyperlactatemia (≥ 4 mmol/L), the frequency of citrate accumulation was 0.77%, 2.70%, and 6.33%, respectively. Receiver operating characteristics-area under the curve of initial lactate concentration was 0.789 for the prediction of citrate accumulation. Optimal cutoff from receiver operating characteristics (2.39 mmol/L) showed strong negative prediction (99.28%), but weak positive prediction (5.21%). The slope intercept of lactate kinetics over 48 hours was positive and significantly higher in patients with citrate accumulation compared to those without (+0.2 vs -0.006 mmol/L/hr; p < 0.001). In patients with initial severe hyperlactatemia (≥ 4 mmol/L), the median calculated lactate clearance at 6, 12, and 18 hours was 24.0%, 48.1%, and 59.4% in the nonaccumulation group. These clearance rates were significantly higher at each time-point compared to patients with citrate accumulation (-9.8%, -20.5%, and 2.3%, respectively; p < 0.001 for each time-point). The highest receiver operating characteristics-area under the curve for citrate accumulation was observed for 12-hour values of lactate clearance (area under the curve = 0.839; 95% CI, 0.751-0.927) with an optimal cut-off value of 24.3%. CONCLUSIONS Risk of citrate accumulation during regional citrate anticoagulation in a well-selected cohort of patients is low even in case of initial severe hyperlactatemia. Lactate kinetics rather than initially elevated lactate concentration should be considered in assessing the risk of citrate accumulation.
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Brandenburger T, Dimski T, Slowinski T, Kindgen-Milles D. Renal replacement therapy and anticoagulation. Best Pract Res Clin Anaesthesiol 2017; 31:387-401. [PMID: 29248145 DOI: 10.1016/j.bpa.2017.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/17/2017] [Indexed: 12/21/2022]
Abstract
Today, up to 20% of all intensive care unit patients require renal replacement therapy (RRT), and continuous renal replacement therapies (CRRT) are the preferred technique. In CRRT, effective anticoagulation of the extracorporeal circuit is mandatory to prevent clotting of the circuit or filter and to maintain filter performance. At present, a variety of systemic and regional anticoagulation modes for CRRT are available. Worldwide, unfractionated heparin is the most widely used anticoagulant. All systemic techniques are associated with significant adverse effects. Most important are bleeding complications and heparin-induced thrombocytopenia (HIT-II). Regional citrate anticoagulation (RCA) is a safe and effective technique. Compared to systemic anticoagulation, RCA prolongs filter running times, reduces bleeding complications, allows effective control of acid-base status, and reduces adverse events like HIT-II. In this review, we will discuss systemic and regional anticoagulation techniques for CRRT including anticoagulation for patients with HIT-II. Today, RCA can be recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.
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Affiliation(s)
- Timo Brandenburger
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Thomas Dimski
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Torsten Slowinski
- Department of Nephrology, University Hospital Charite, Campus Mitte, Chariteplatz 2, Berlin D-10117, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany.
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Rodriguez K, Srivaths PR, Tal L, Watson MN, Riley AA, Himes RW, Desai MS, Braun MC, Akcan Arikan A. Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure. PLoS One 2017; 12:e0182134. [PMID: 28792509 PMCID: PMC5549692 DOI: 10.1371/journal.pone.0182134] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/12/2017] [Indexed: 01/20/2023] Open
Abstract
Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75-14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29-74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.
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Affiliation(s)
- Keila Rodriguez
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Poyyapakkam R. Srivaths
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Leyat Tal
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Mary N Watson
- Texas Children’s Hospital, Houston, Texas, United States of America
| | - Alyssa A. Riley
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ryan W. Himes
- Baylor College of Medicine, Department of Pediatrics, Liver Section, Houston, Texas, United States of America
| | - Moreshwar S. Desai
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
| | - Michael C. Braun
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ayse Akcan Arikan
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
- * E-mail:
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46
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Bellomo R, Ronco C, Mehta RL, Asfar P, Boisramé-Helms J, Darmon M, Diehl JL, Duranteau J, Hoste EAJ, Olivier JB, Legrand M, Lerolle N, Malbrain MLNG, Mårtensson J, Oudemans-van Straaten HM, Parienti JJ, Payen D, Perinel S, Peters E, Pickkers P, Rondeau E, Schetz M, Vinsonneau C, Wendon J, Zhang L, Laterre PF. Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference. Ann Intensive Care 2017. [PMID: 28474317 DOI: 10.1186/s13613-017-0260-y.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools,
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Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of ICU, Austin Health, Heidelberg, Australia
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Ravindra L Mehta
- Vice Chair Clinical Research, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France.,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, PRES L'UNAM, Angers, France
| | - Julie Boisramé-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de médecine, Université de Strasbourg, Strasbourg, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jean Monnet University, Saint-Étienne, France
| | - Jean-Luc Diehl
- Medical ICU, AP-HP, Georges Pompidou European Hospital, Paris, France.,INSERM UMR_S1140, Paris Descartes University and Sorbonne Paris Cité, Paris, France
| | - Jacques Duranteau
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Eric A J Hoste
- ICU, Ghent University Hospital, Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
| | | | - Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Hôpitaux Universitaire St-Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Paris, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale et de Médecine Hyperbare, CHU, Angers, France
| | | | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jean-Jacques Parienti
- Department of Infectious Diseases, University Hospital, Caen, France.,Department of Biostatistic and Clinical Research, University Hospital, Caen, France
| | - Didier Payen
- Department of Anesthesia and Critical Care, SAMU, Lariboisière University Hospital, Paris, France
| | - Sophie Perinel
- Medical-Surgical ICU, Saint-Etienne University Hospital, Jean Monnet University Saint-Etienne, Saint-Étienne, France
| | - Esther Peters
- Department of Pharmacology and Toxicology, Radboud university Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Rondeau
- Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Paris 6, Paris, France
| | - Miet Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Christophe Vinsonneau
- Service de Réanimation et Surveillance continue, Centre Hospitalier de BETHUNE, Bethune, France
| | - Julia Wendon
- Kings College Hospital Foundation Trust, London, UK
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
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47
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Bellomo R, Ronco C, Mehta RL, Asfar P, Boisramé-Helms J, Darmon M, Diehl JL, Duranteau J, Hoste EAJ, Olivier JB, Legrand M, Lerolle N, Malbrain MLNG, Mårtensson J, Oudemans-van Straaten HM, Parienti JJ, Payen D, Perinel S, Peters E, Pickkers P, Rondeau E, Schetz M, Vinsonneau C, Wendon J, Zhang L, Laterre PF. Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference. Ann Intensive Care 2017; 7:49. [PMID: 28474317 PMCID: PMC5418176 DOI: 10.1186/s13613-017-0260-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools,
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Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of ICU, Austin Health, Heidelberg, Australia
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Ravindra L Mehta
- Vice Chair Clinical Research, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France.,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, PRES L'UNAM, Angers, France
| | - Julie Boisramé-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de médecine, Université de Strasbourg, Strasbourg, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jean Monnet University, Saint-Étienne, France
| | - Jean-Luc Diehl
- Medical ICU, AP-HP, Georges Pompidou European Hospital, Paris, France.,INSERM UMR_S1140, Paris Descartes University and Sorbonne Paris Cité, Paris, France
| | - Jacques Duranteau
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Eric A J Hoste
- ICU, Ghent University Hospital, Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
| | | | - Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Hôpitaux Universitaire St-Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Paris, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale et de Médecine Hyperbare, CHU, Angers, France
| | | | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jean-Jacques Parienti
- Department of Infectious Diseases, University Hospital, Caen, France.,Department of Biostatistic and Clinical Research, University Hospital, Caen, France
| | - Didier Payen
- Department of Anesthesia and Critical Care, SAMU, Lariboisière University Hospital, Paris, France
| | - Sophie Perinel
- Medical-Surgical ICU, Saint-Etienne University Hospital, Jean Monnet University Saint-Etienne, Saint-Étienne, France
| | - Esther Peters
- Department of Pharmacology and Toxicology, Radboud university Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Rondeau
- Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Paris 6, Paris, France
| | - Miet Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Christophe Vinsonneau
- Service de Réanimation et Surveillance continue, Centre Hospitalier de BETHUNE, Bethune, France
| | - Julia Wendon
- Kings College Hospital Foundation Trust, London, UK
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
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Tan JN, Haroon SWP, Mukhopadhyay A, Lau T, Murali TM, Phua J, Tan ZY, Lee N, Chua HR. Hyperlactatemia Predicts Citrate Intolerance With Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy. J Intensive Care Med 2017; 34:418-425. [PMID: 28372501 DOI: 10.1177/0885066617701068] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE: We aim to determine whether hyperlactatemia, which suggests multi-organ dysfunction and impaired organic substrate metabolism, may predict intolerance to regional citrate anticoagulation (RCA) during continuous venovenous hemofiltration (CVVH). METHODS: We performed a single-center, retrospective observational study in critically ill patients with acute kidney injury or end-stage renal disease and evaluated the association of peak serum lactate levels with citrate intolerance (CI) during the initial 72 hours of RCA-CVVH, defined by serum total-to-ionized calcium >2.5 plus systemic hypocalcemia. RESULTS: Eighty-eight patients were studied (aged 59 ± 14 years, 66% males, Acute Physiology and Chronic Health Evaluation II: 31 ± 8). Citrate was dosed at median 2.1 mmol/L of blood flow, with citrate load of 30 mmol/h, and CVVH effluent of 43 mL/kg/h. Twenty patients developed CI. Comparing patients with CI versus none, peak lactate levels were 8 (5-11) versus 3 (2-6) mmol/L, calcium replacement was 13 (10-17) versus 11 (8-12) mmol/h, and standard base excess was -4 (-12 to 1) versus 2(-4 to 7) mmol/L, respectively ( P < .05). Citrate intolerance developed in 38%, 44%, and 55%, in patients with peak lactate >4, >6, >7 mmol/L, respectively, versus 7% in those with peak lactate ≤4 mmol/L ( P ≤ .001), despite comparable citrate load and effluent rates across all categories. On multivariate analysis, hyperlactatemia and hyperbilirubinemia predicted CI ( P ≤ .01), which was associated with increasing calcium infusion requirement. Higher peak lactate from >4 to >7 mmol/L predicted CI with graded increase in odds ratio and specificity from 59% to 87%, but the corresponding negative predictive value from 93% to 87%. Area under nonparametric receiver operating characteristic curve for peak lactate and CI was 0.78. CONCLUSION: Hyperlactatemia predicts CI during RCA-CVVH with reasonable discriminatory performance in critically ill patients. Serum lactate surveillance may help preempt issues with citrate toxicity.
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Affiliation(s)
- Jia-Neng Tan
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Sabrina Wong Peixin Haroon
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Amartya Mukhopadhyay
- 2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.,3 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Republic of Singapore
| | - Titus Lau
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Tanusya M Murali
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Jason Phua
- 2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.,3 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Republic of Singapore
| | - Zong-Yao Tan
- 4 National University of Singapore High School of Mathematics and Science, Republic of Singapore
| | - Nicholas Lee
- 4 National University of Singapore High School of Mathematics and Science, Republic of Singapore
| | - Horng-Ruey Chua
- 1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.,2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
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Ion-Exchange Resin Anticoagulation (I-ERA): A Novel Extracorporeal Technique for Regional Anticoagulation. Shock 2016; 46:304-11. [PMID: 26939038 DOI: 10.1097/shk.0000000000000597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extracorporeal treatments always require blood anticoagulation. We tested feasibility and efficacy of a novel technique for regional extracorporeal blood anticoagulation based on calcium removal by ion-exchange resins (i-ER), called ion-exchange resin anticoagulation (i-ERA). METHODS Eight swine were connected to a veno-venous extracorporeal circuit comprising a hemodiafilter and an i-ER. Blood flow was 150 mL/min. Hemodiafiltrate was generated at 975 mL/min and passed through the i-ER. A fraction of the calcium-free hemodiafiltrate was returned to the hemodiafilter (675 mL/min), while the remaining was recirculated prior the hemodiafilter (300 mL/min) to dilute blood entering the hemodiafilter. A calcium replacement solution was continuously infused. Two hours after i-ERA start, blood was sampled from inlet, before the hemodiafilter (prehemodiafilter blood) and from outlet of the extracorporeal circuit for ionized calcium (iCa) concentration and thromboelastography (TEG). Arterial blood was collected for blood gas analyses, electrolytes concentrations, and plasma free hemoglobin. Hemodynamics and ventilation were monitored. RESULTS i-ERA reduced iCa from 1.28 ± 0.05 mmol/L (inlet) to 0.47 ± 0.03 mmol/L (prehemodiafilter blood) and 0.25 ± 0.03 mmol/L (outlet). Prehemodiafilter blood and outlet samples showed no sign of clot formation (reaction time (R) >60 min; maximal amplitude (MA) = 0 (0-0) mm), while blood-inlet had normal coagulation (R = 8.5 (5.8-10.2) min; MA = 65.2 (63.2-68.7) mm). Arterial gas analyses and electrolytes concentrations, hemodynamics, and ventilation were unchanged. No hemolysis was recorded. CONCLUSIONS In a swine model, i-ERA proved feasible and effective in reducing iCa and preventing clot formation with TEG analyses. Further studies are warranted to evaluate the long-term efficacy and safety of i-ERA. LEVEL OF EVIDENCE V-therapeutic animal experiment.
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50
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Kindgen-Milles D, Ostermann M, Slowinski T. Ionized calcium measurements during regional citrate anticoagulation in CRRT: we need better blood gas analyzers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:427. [PMID: 26645989 PMCID: PMC4673790 DOI: 10.1186/s13054-015-1143-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, D-40225, Düsseldorf, Germany.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St. Thomas' Foundation Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Torsten Slowinski
- Department of Nephrology, Charité Universitätsmedizin Berlin, Campus Mitte (CCM), Charitéplatz 1, D-10117, Berlin, Germany.
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