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Hasan MS, Jamaludin MA, Mohd Azman SA, Atan R, Yap MH, Lee ZY, Mohd Yunos N. Early experience of using regional citrate anticoagulation for continuous renal replacement therapy in critically ill patients in a resource-limited setting. Nephrology (Carlton) 2024; 29:528-536. [PMID: 38830816 DOI: 10.1111/nep.14330] [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: 01/24/2024] [Revised: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
AIM Despite the superiority of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT), its application is limited in resource-limited settings. We aim to explore the cost and safety of RCA for CRRT in critically ill patients, compared to usual care. METHODS This prospective observational study included patients requiring CRRT in a tertiary intensive care unit (ICU) from February 2022 to January 2023. They were classified to either the RCA or usual care groups based on the anticoagulation technique chosen by the treating physician, considering contraindications. The CRRT prescription follows the institutional protocol. All relevant data were obtained from the ICU CRRT-RCA charts and electronic medical records. A cost analysis was performed. RESULTS A total of 54 patients (27 per group) were included, with no demographic differences. Sequential Organ Failure Assessment score and lactate levels were significantly higher in the usual care group. The number of filters used were comparable (p = .108). The median filter duration in the RCA group was numerically longer (35.00 [15.50-56.00] vs. 23.00 [17.00-29.00] h), but not statistically significant (p = .253). The duration of mechanical ventilation, vasopressor requirement, and mortality were similar, but the RCA group had a significantly longer ICU stay. The rate of adverse events was similar, with four severe metabolic alkalosis cases in the RCA group. The RCA group had higher total cost per patient per day (USD 611 vs. 408; p = .013). CONCLUSION In this resource-limited setting, RCA for CRRT appeared safe and had clinically longer filter lifespan compared with usual care, albeit the increased cost.
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Affiliation(s)
- M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Afif Jamaludin
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | - Rafidah Atan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Hoon Yap
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
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Huang S, Sun G, Wu P, Wu L, Jiang H, Wang X, Li L, Gao L, Meng F. Safety and Feasibility of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy With Calcium-Containing Solutions: A Randomized Controlled Trial. Semin Dial 2024; 37:249-258. [PMID: 38439685 DOI: 10.1111/sdi.13200] [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: 08/14/2023] [Revised: 10/10/2023] [Accepted: 02/02/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Calcium-free (Ca-free) solutions are theoretically the most ideal for regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT). However, the majority of medical centers in China had to make a compromise of using commercially available calcium-containing (Ca-containing) solutions instead of Ca-free ones due to their scarcity. This study was designed to probe into the potential of Ca-containing solution as a secure and efficient substitution for Ca-free solutions. METHODS In this prospective, randomized single-center trial, 99 patients scheduled for CRRT were randomly assigned in a 1:1:1 ratio to one of three treatment groups: continuous veno-venous hemodialysis Ca-free dialysate (CVVHD Ca-free) group, continuous veno-venous hemodiafiltration calcium-free dialysate (CVVHDF Ca-free) group, and continuous veno-venous hemodiafiltration Ca-containing dialysate (CVVHDF Ca-containing) group at cardiac intensive care unit (CICU). The primary endpoint was the incidence of metabolic complications. The secondary endpoints included premature termination of treatment, thrombus of filter, and bubble trap after the process. RESULTS The incidence of citrate accumulation (18.2% vs. 12.1% vs. 21.2%) and metabolic alkalosis (12.1% vs. 0% vs. 9.1%) did not significantly differ among three groups (p > 0.05 for both). The incidence of premature termination was comparable among the groups (18.2% vs. 9.1% vs. 9.1%, p = 0.582). The thrombus level of the filter and bubble trap was similar in the three groups (p > 0.05 for all). CONCLUSIONS In RCA-CRRT for CICU population, RCA-CVVHDF with Ca-containing solutions and traditional RCA with Ca-free solutions had a comparable safety and feasibility. TRIAL REGISTRATION ChiCTR2100048238 in the Chinese Clinical Trial Registry.
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Affiliation(s)
- Shan Huang
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Guangfeng Sun
- Department of Emergency, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Penglong Wu
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - LinJing Wu
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hongfei Jiang
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xixing Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Liyuan Li
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Lingling Gao
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Fanqi Meng
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
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Atis SK, Duyu M, Karakaya Z, Yilmaz A. Citrate anticoagulation and systemic heparin anticoagulation during continuous renal replacement therapy among critically-ill children. Pediatr Res 2024:10.1038/s41390-024-03163-x. [PMID: 38555381 DOI: 10.1038/s41390-024-03163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
BAKCGROUND The aim of this study was to evaluate the efficacy and safety of citrate versus heparin anticoagulation for CRRT in critically-ill children. METHODS This retrospective comparative cohort reviewed the clinical records of critically-ill children undergoing CRRT with either RCA or systemic heparin anticoagulation. The primary outcome measure was hemofilter survival time. Secondary outcomes included the comparison of complications and metabolic disorders. RESULTS A total of 131 patients (55 RCA and 76 systemic heparin) were included, in which a cumulative number of 280 hemofilters were used (115 in RCA with 5762 h total CRRT time, and 165 in systemic heparin with 6230 h total CRRT time). Hemofilter survival was significantly longer for RCA (51.0 h; IQR: 24-67 h) compared to systemic heparin (29.5 h; IQR, 17-48 h) (p = 0.002). Clotting-related hemofilter failure occurred in 9.6% of the RCA group compared to 19.6% in the systemic heparin group (p = 0.038). Citrate accumulation occurred in 4 (3.5%) of 115 RCA sessions. Hypocalcemia and metabolic alkalosis episodes were significantly more frequent in RCA recipients (35.7% vs 15.2%, p < 0.0001; 33.0% vs 19.4%, p = 0.009). CONCLUSION RCA is a safe and effective anticoagulation method for CRRT in critically-ill children and it prolongs hemofilter survival. IMPACT RCA is superior to systemic heparin for the prolongation of circuit survival (overall and for clotting-related loss) during CRRT. These data indicate that RCA can be used to maximize the effective delivery of CRRT in critically-ill patients admitted to the PICU. There are potential cost-saving implications from our results owing to benefits such as less circuit downtime and fewer circuit changes.
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Affiliation(s)
- Seyma Koksal Atis
- Department of Pediatrics, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey.
| | - Muhterem Duyu
- Pediatric Intensive Care Unit, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Zeynep Karakaya
- Department of Pediatrics, Istanbul Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Alev Yilmaz
- Department of Pediatrics, Division of Pediatric Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkey
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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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Szamosfalvi B, Heung M. Citrate Anticoagulation for CKRT with Liver Failure: Ready for Prime Time? Clin J Am Soc Nephrol 2024; 19:139-141. [PMID: 38109078 PMCID: PMC10861106 DOI: 10.2215/cjn.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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Dos Santos TOC, Dos Santos Ferreira CE, Mangueira CLP, Ammirati AL, Scherer PF, Doher MP, Matsui TN, Dos Santos BFC, Pereira VG, Batista MC, Monte JCM, Santos OFP, de Souza Durão M. Hypercitratemia is a mortality predictor among patients on continuous venovenous hemodiafiltration and regional citrate anticoagulation. Sci Rep 2023; 13:20176. [PMID: 37978209 PMCID: PMC10656486 DOI: 10.1038/s41598-023-47644-1] [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: 10/07/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
The use of regional citrate anticoagulation (RCA) in liver failure (LF) patients can lead to citrate accumulation. We aimed to evaluate serum levels of citrate and correlate them with liver function markers and with the Cat/Cai in patients under intensive care and undergoing continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA). A prospective cohort study in an intensive care unit was conducted. We compared survival, clinical, laboratorial and dialysis data between patients with and without LF. Citrate was measured daily. We evaluated 200 patients, 62 (31%) with LF. Citrate was significantly higher in the LF group. Dialysis dose, filter lifespan, systemic ionized calcium and Cat/Cai were similar between groups. There were weak to moderate positive correlations between Citrate and indicators of liver function and Cat/Cai. The LF group had higher mortality (70.5% vs. 51.8%, p = 0.014). Citrate was an independent risk factor for death, OR 11.3 (95% CI 2.74-46.8). In conclusion, hypercitratemia was an independent risk factor for death in individuals undergoing CVVHDF-ARC. The increase in citrate was limited in the LF group, without clinical significance. The correlation between citrate and liver function indicators was weak to moderate.
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Affiliation(s)
- Thais Oliveira Claizoni Dos Santos
- Nephrology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, São Paulo, SP, 04023-062, Brazil
- School of Medicine, Universidade de Pernambuco, Recife, PE, Brazil
| | | | | | - Adriano Luiz Ammirati
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Dialysis Center, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Patricia Faria Scherer
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - Thais Nemoto Matsui
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Bento Fortunato Cardoso Dos Santos
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Dialysis Center, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - Marcelo Costa Batista
- Nephrology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, São Paulo, SP, 04023-062, Brazil
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Julio Cesar Martins Monte
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | - Oscar Fernando Pavão Santos
- Nephrology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, São Paulo, SP, 04023-062, Brazil
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Marcelino de Souza Durão
- Nephrology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, São Paulo, SP, 04023-062, Brazil.
- Nephrology Division, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil.
- Kidney Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Whiting L, Bianchi N, Faouzi M, Schneider A. Kinetics of small and middle molecule clearance during continuous hemodialysis. Sci Rep 2023; 13:12905. [PMID: 37558740 PMCID: PMC10412530 DOI: 10.1038/s41598-023-40075-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: 10/10/2022] [Accepted: 08/04/2023] [Indexed: 08/11/2023] Open
Abstract
Regional citrate anticoagulation (RCA) enables prolonged continuous kidney replacement therapy (CKRT) filter lifespan. However, membrane diffusive performance might progressively decrease and remain unnoticed. We prospectively evaluated the kinetics of solute clearance and factors associated with decreased membrane performance in 135 consecutive CKRT-RCA circuits (35 patients). We recorded baseline patients' characteristics and clinical signs of decreased membrane performance. We calculated effluent/serum ratios (ESR) as well as respective clearances for urea, creatinine and β2-microglobuline at 12, 24, 48 and 72 h after circuit initiation. Using mixed-effects logistic regression model analyses, we assessed the effect of time on those values and determined independent predictors of decreased membrane performance as defined by an ESR for urea < 0.81. We observed a minor but statistically significant decrease in both ESR and solute clearance across the duration of therapy for all three solutes. We observed decreased membrane performance in 31 (23%) circuits while clinical signs were present in 19 (14.1%). The risk of decreased membrane performance significantly increased over time: 1.8% at T1 (p = 0.16); 7.3% at T2 (p = 0.01); 15.7% at T3 (p = 0.001) and 16.4% at T4 (p < 0.003). Four factors present within 24 h of circuit initiation were independently associated with decreased membrane performance: arterial blood bicarbonate level (OR 1.50; p < 0.001), activated partial thromboplastin time (aPTT; OR = 0.93; p = 0.02), fibrinogen level (OR 6.40; p = 0.03) and Charlson score (OR 0.10; p < 0.01). COVID-19 infection was not associated with increased risk of decreased membrane performance. Regular monitoring of ESR might be appropriate in selected patients undergoing CKRT.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nathan Bianchi
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mohamed Faouzi
- Division of Biostatistics, Center for Primary Care and Public Health (UNISANTE), University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Liu J, Liu Z, Zhao T, Su T, Jin Q. Thromboelastography and Traditional Coagulation Testing in Non-ICU-Admitted Patients with Acute Kidney Injury: An Observational Cohort Study. Am J Nephrol 2023; 54:208-218. [PMID: 37364534 DOI: 10.1159/000530777] [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: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION This study aimed to elucidate the coagulation disorders in non-ICU patients with acute kidney injury (AKI) and their contribution to clotting-related outcomes of intermittent kidney replacement therapy (KRT). METHODS We included non-ICU-admitted patients with AKI requiring intermittent KRT, clinically having a risk of bleeding and against systemic anticoagulant use during KRT between April and December 2018. The premature termination of treatment due to circuit clotting was considered a poor outcome. We analyzed the characteristics of thromboelastography (TEG)-derived and traditional coagulation parameters and explored the potential-affecting factors. RESULTS In total, 64 patients were enrolled. Hypocoagulability was detected in 4.7%-15.6% of patients by a combination of the traditional parameters, i.e., prothrombin time (PT)/international normalized ratio, activated partial PT, and fibrinogen. No patient had hypocoagulability observed on TEG-derived reaction time; only 2.1%, 3.1%, and 10.9% of patients had hypocoagulability on TEG-derived kinetic time (K-time), α-angle, and maximum amplitude (MA), respectively, which were also platelet-related coagulation parameters, despite 37.5% of the cohort having thrombocytopenia. In contrast, hypercoagulability was more prevalent, involving 12.5%, 43.8%, 21.9%, and 48.4% of patients on TEG K-time, α-angle, MA, and coagulation index (CI), respectively, although thrombocytosis was only in 1.5% of the cohort. Patients with thrombocytopenia showed lower fibrinogen level (2.6 vs. 4.0 g/L, p = 0.00), α-angle (63.5° vs. 73.3°, p = 0.00), MA (53.5 vs. 66.1 mm, p = 0.00), and CI (1.8 vs. 3.6, p = 0.00) but higher thrombin time (17.8 vs. 16.2 s, p = 0.00) and K-time (2.0 vs. 1.2 min, p = 0.00) than those with a platelet count over 100 × 109/L. 41 patients were treated with heparin-free protocol, and 23 were treated with regional citrate anticoagulation (RCA). The premature termination rate was 41.5% on heparin-free patients, while 8.7% of patients underwent an RCA protocol (p = 0.006). Heparin-free protocol was the strongest adverse factor to poor outcomes. A heparin-free subgroup analysis found that the circuit clotting risk was increased by 61.7% with a 10 × 109/L elevation in platelet count (odds ratio [OR] = 1.617, p = 0.049) and decreased by 67.5% following a second increase of PT (OR = 0.325, p = 0.041). No significant correlation was found between TEG parameters and premature circuit clotting. CONCLUSIONS Most non-ICU-admitted patients with AKI had normal-to-enhanced hemostasis and activated platelet function based on TEG results, as well as a high rate of premature circuit clotting when receiving heparin-free protocol despite thrombocytopenia. Further studies are needed to better determine the use of TEG in respect to management of anticoagulation and bleeding complications in AKI patients with KRT.
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Affiliation(s)
- Jiajia Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Zhongyuan Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Tao Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
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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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Sanchez AP, Ward DM, Cunard R. Therapeutic plasma exchange in the intensive care unit: Rationale, special considerations, and techniques for combined circuits. Ther Apher Dial 2022; 26 Suppl 1:41-52. [PMID: 36468345 DOI: 10.1111/1744-9987.13814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/07/2022] [Indexed: 12/11/2022]
Abstract
Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique with proven efficacy in a variety of conditions, including in the intensive care setting. It is not uncommon for a critically ill patient to require more than one extracorporeal procedure in addition to TPE. This review focuses on the combination of TPE with other extracorporeal circuits in a critical care setting via a single vascular access (either in-series, parallel, or a hybrid mode) which is often referred to as performing procedures "in tandem." Authors performed literature review via pubmed.gov using search terms: plasma exchange, plasmapheresis, apheresis, tandem circuits, combined circuits, critical care, ICU, CRRT, hemodialysis, and ECMO. Thirty-eight English-language, peer-reviewed papers were appraised that satisfied the content of this review on techniques for combining circuits with plasma exchange, as well as describing the advantages of tandem procedures and potential complications that can arise. Performing these procedures simultaneously can be advantageous in reducing total procedure and staffing time, avoiding placement of additional central lines, reducing overall need for anticoagulation, and limiting multiple blood primes in certain populations. However, the described combined circuits are complex, associated with higher complications, and require a skilled team to understand and mitigate the potential complications associated with these combined procedures.
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Affiliation(s)
- Amber P Sanchez
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - David M Ward
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - Robyn Cunard
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA.,Veterans Affairs San Diego Healthcare System, San Diego, California, USA
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11
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Anticoagulation in patients with acute kidney injury undergoing kidney replacement therapy. Pediatr Nephrol 2022; 37:2303-2330. [PMID: 34668064 DOI: 10.1007/s00467-021-05020-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/13/2020] [Accepted: 02/18/2021] [Indexed: 10/20/2022]
Abstract
Kidney replacement therapy (KRT) is used to provide supportive therapy for critically ill patients with severe acute kidney injury and various other non-renal indications. Modalities of KRT include continuous KRT (CKRT), intermittent hemodialysis (HD), and sustained low efficiency daily dialysis (SLED). However, circuit clotting is a major complication that has been investigated extensively. Extracorporeal circuit clotting can cause reduction in solute clearances and can cause blood loss, leading to an upsurge in treatment costs and a rise in workload intensity. In this educational review, we discuss the pathophysiology of the clotting cascade within an extracorporeal circuit and the use of various types of anticoagulant methods in various pediatric KRT modalities.
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12
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Whiting L, Bianchi NA, Alouazen K, Joannes-Boyau O, Chiche JD, Schneider A. Validation of a Protocol for Continuous Hemodiafiltration with Regional Citrate Anticoagulation with Omni®. Blood Purif 2022; 51:1039-1047. [PMID: 35636389 PMCID: PMC9808739 DOI: 10.1159/000524329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Omni® (B Braun, Melsungen, Germany) is able to run continuous renal replacement therapy (CRRT) in continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF) modes. However, to date, there is no validated protocol to guide the use of Omni® in CVVHDF mode with regional citrate anticoagulation (RCA). METHODS We designed a protocol for CVVHDF-RCA tailored for Omni®. This protocol was tested in patients included in an observational study conducted in our center between January and March 2021. For all study patients, we collected baseline characteristics, laboratory results, CRRT circuit lifespan as well as plasma and effluent samples at 12, 24, 48, and 72 h of CRRT circuit initiation. At each study time point, we computed urea, creatinine, and β2-microglobulin clearance as well as effluent/blood ratios. Data from circuits in CVVHDF-RCA mode are compared with those in standard therapy (CVVHD-RCA) with the same device. RESULTS We analyzed ten circuits (5 patients) in CVVHDF-RCA mode and 32 (13 patients) in CVVHD-RCA mode. No adverse events related to the therapy were observed. In CVVHDF-RCA mode, median circuit running time was 68 (IQR 8.1) hours versus 46 (IQR 9.0) in CVVHD mode, p = 0.053. Therapy adaptations (dialysate rate and/or blood flow) were required in one (10%) circuit (15.6% in CVVHD mode, p = 0.56). Compared to CVVHD, CVVHDF was able to achieve similar clearance and effluent/blood ratio for urea, creatinine, and β2-microglobulin across the entire duration of circuit lifetime. CONCLUSION The proposed protocol for CVVHDF-RCA for Omni® was associated with similar circuit lifetime, number of required adaptations and clearances to standard CVVHD-RCA. It appears to be safe and feasible.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland,
| | - Nathan Axel Bianchi
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Karima Alouazen
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Jean-Daniel Chiche
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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13
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Anstey CM, Venkatesh B. A Comparison of the Commonly Used Surrogate Markers for Citrate Accumulation and Toxicity during Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2022; 51:997-1005. [PMID: 35443247 DOI: 10.1159/000524129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Continuous renal replacement therapy using regional citrate anticoagulation is commonly used as a modality of organ support in the critically ill population. Currently, citrate accumulation or toxicity is assessed using surrogate markers, notably the uncorrected total-to-ionized calcium ration. The accuracy and utility of this method have been questioned. OBJECTIVES/AIMS The aim of this study was to compare the surrogate markers used for assessing citrate accumulation or toxicity using the measurement of plasma citrate as the gold standard. METHODS Blood was sampled from 20 patients before, during, and after episodes of filtration with citrate concentration measured using spectrophotometry. Demographic and other clinical and biochemical data were also collected. According to protocol, a 15 mmol/L solution of trisodium citrate was used as the prefilter anticoagulant. Results were analyzed using STATA (v16.0) and presented as mean (SD), median (IQR), or simple proportion. Univariate linear regression using citrate concentration as the dependent variable was performed with all surrogate markers. RESULTS Twenty patients (17 males) were enrolled in the study with a mean (SD) age of 62.7 (9.9) years. The uncorrected calcium ratio had the best fit to the citrate data with an R2 value of 0.39. The albumin-corrected calcium ratio, pH, anion gap (AG), albumin-corrected AG, standard base excess, and strong ion gap all had R2 values less than 0.05. CONCLUSION(S) In the absence of direct measurement of citrate concentration, uncorrected total-to-ionized calcium ratio is superior to other surrogate markers, though not ideal, in assessing citrate accumulation or toxicity.
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Affiliation(s)
- Chris M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Queensland, Australia
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14
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Abstract
Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.
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15
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Raina R, Sethi S, Khooblall A, Kher V, Deshpande S, Yerigeri K, Pandya A, Nair N, Datla N, McCulloch M, Bunchman T, Davenport A. Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life. Hemodial Int 2022; 26:147-159. [PMID: 34989465 DOI: 10.1111/hdi.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently. METHODS This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies. FINDINGS The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 106 /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances. DISCUSSIONS With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Amrit Khooblall
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Shweta Deshpande
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Keval Yerigeri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Aadi Pandya
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nikhil Nair
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Nithin Datla
- Akron Nephrology Associates, Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA.,Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
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16
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Samoni S, Husain-Syed F, Villa G, Ronco C. Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence. J Clin Med 2021; 11:172. [PMID: 35011913 PMCID: PMC8745413 DOI: 10.3390/jcm11010172] [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] [Received: 09/21/2021] [Revised: 12/24/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
The history of continuous renal replacement therapy (CRRT) is marked by technological advances linked to improvements in the knowledge of the mechanisms and kinetics of extracorporeal removal of solutes, and the pathophysiology of acute kidney injury (AKI) and other critical illnesses. In the present article, we review the main steps in the history of CRRT, from the discovery of continuous arteriovenous hemofiltration to its evolution into the current treatments and its early use in the treatment of AKI, to the novel sequential extracorporeal therapy. Beyond the technological advances, we describe the development of new medical specialties and a shared nomenclature to support clinicians and researchers in the broad and still evolving field of CRRT.
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Affiliation(s)
- Sara Samoni
- Department of Nephrology and Dialysis, S. Anna Hospital, ASST Lariana, 22042 Como, Italy;
| | - Faeq Husain-Syed
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, 35392 Giessen, Germany;
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, 50134 Florence, Italy
| | - Claudio Ronco
- Department of Medicine (DIMED), University of Padova, 35121 Padova, Italy;
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), St. Bortolo Hospital, 36100 Vicenza, Italy
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17
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Efficacy and complications of regional citrate anticoagulation during continuous renal replacement therapy in critically ill patients with COVID-19. J Crit Care 2021; 67:126-131. [PMID: 34768173 PMCID: PMC8576341 DOI: 10.1016/j.jcrc.2021.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 12/23/2022]
Abstract
Background We compared filter survival and citrate-induced complications during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in COVID-19 and Non-COVID-19 patients. Methods In this retrospective study we included all consecutive adult patients (n = 97) treated with RCA-CRRT. Efficacy and complications of RCA-CRRT were compared between COVID-19 and Non-COVID-19 patients. Results Mean filter run-time was significantly higher in COVID-19 patients compared to Non-COVID-19 patients (68.4 (95%CI 67.0–69.9) vs. 65.2 (95%CI 63.2–67.2) hours, respectively; log-rank 0.014). COVID-19 patients showed significantly higher activated partial thromboplastin time (aPTT) throughout the CRRT due to intensified systemic anticoagulation compared to Non-COVID-19 patients (54 (IQR 45–61) vs. 47 (IQR 41–58) seconds, respectively; p < 0.001). A significantly higher incidence of metabolic alkalosis, hypercalcemia and hypernatremia, consistent with reduced filter patency and citrate overload, was observed in COVID-19 patients compared to Non-COVID-19 patients (19.1% vs. 12.7%, respectively; p = 0.04). These metabolic disarrangements were resistant to per-protocol adjustments and disappeared after replacement of the CRRT-filter. Conclusions RCA-CRRT in COVID-19 patients with intensified systemic anticoagulation provides an adequate filter lifespan. However, close monitoring of the acid-base balance appears warranted, as these patients tend to develop reduced filter patency leading to a higher incidence of citrate overload and metabolic disturbances. Trial registration (local authority) EA1/285/20 (Ethikkommission der Charité - Universitätsmedizin Berlin); date of registration 08.10.2020.
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18
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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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19
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Yessayan L, Sohaney R, Puri V, Wagner B, Riddle A, Dickinson S, Napolitano L, Heung M, Humes D, Szamosfalvi B. Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance. BMC Nephrol 2021; 22:244. [PMID: 34215201 PMCID: PMC8249839 DOI: 10.1186/s12882-021-02443-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13). CONCLUSIONS The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.
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Affiliation(s)
- Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
| | - Ryann Sohaney
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Vidhit Puri
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Benjamin Wagner
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Amy Riddle
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Sharon Dickinson
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lena Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
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20
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Regional citrate anti-coagulation dose titration: impact on dose of continuous renal replacement therapy. Clin Exp Nephrol 2021; 25:963-969. [PMID: 33885995 DOI: 10.1007/s10157-021-02064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Regional citrate anti-coagulation (RCA) is the recommended anti-coagulation for continuous renal replacement therapy (CRRT). Citrated replacement fluids provide convenience but may compromise effluent delivery when adjusted to maintain circuit ionised calcium levels (circuit-iCa). This study aims to evaluate the effect of RCA titration on the delivered CRRT effluent dose. METHODS This prospective observational study evaluated patients on RCA-CRRT in continuous veno-venous hemodiafiltration mode. Citrated replacement fluid was titrated to target circuit-iCa 0.26-0.40 mmol/L. Patients were then stratified into 'reduced-dose' who required citrate down-titration and 'stable-dose' who did not. RESULTS Data from 200 RCA-CRRT sessions were collected. The reduced-dose RCA group (n = 114) had higher median initial citrate dose (3.00 vs 2.50; P < 0.001) but lower time-averaged dose (2.49 vs 2.60; P < 0.001). In addition, median prescribed effluent dose was 33.3 mL/kg/h (28.6-39.2) but median delivered effluent dose was significantly lower at 29.9 mL/kg/h (25.4-36.9; P < 0.001). Mortality was higher in the reduced-dose RCA group (39.5% vs 25.6%; P = 0.022) and in patients with delivered-to-prescribed effluent dose ratio of < 0.9 vs ≥ 0.9 (51.3% vs 29.2%; P = 0.014). CONCLUSION RCA titration can significantly impact delivered CRRT effluent dose. Measures should be taken to address the CRRT dose deficit and prevent poor outcomes due to inadequate dialysis.
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21
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Rhee H, Berenger B, Mehta RL, Macedo E. Regional Citrate Anticoagulation for Continuous Kidney Replacement Therapy With Calcium-Containing Solutions: A Cohort Study. Am J Kidney Dis 2021; 78:550-559.e1. [PMID: 33798636 DOI: 10.1053/j.ajkd.2021.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Regional citrate anticoagulation (RCA) is the preferred anticoagulation method for continuous kidney replacement therapy (CKRT) recommended by KDIGO. Limited availability of calcium-free solutions often imposes challenges to the implementation of RCA for CKRT (RCA-CKRT). The principal purpose of this study was to characterize the outcomes of RCA-CKRT using calcium-containing solutions. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS We evaluated the safety and efficacy of RCA-CKRT with calcium-containing dialysate and replacement fluid used for 128 patients. A total of 571 filters and 1,227 days of CKRT were analyzed. EXPOSURES Liver disease, sepsis in the absence of liver disease, and sepsis with liver disease. OUTCOMES Filter life and metabolic complications per 100 CKRT days. ANALYTICAL APPROACH Linear mixed-effects model and generalized linear mixed-effects models. RESULTS The majority of patients were male (91; 71.1%), 32 (25%) had liver disease, and 29 (22.7%) had sepsis without liver disease. Median filter life was 50.0 (interquartile range, 22.0-118.0) hours, with a maximum of 322 hours, and was significantly lower (33.5 [interquartile range, 17.5-60.5] h) in patients with liver disease. Calcium-containing replacement solutions were used in 41.6% of all CKRT hours and reduced intravenous calcium requirements by 31.7%. Hypocalcemia (ionized calcium<0.85mmol/L) and hypercalcemia (total calcium>10.6mg/dL) were observed in 6.0 and 6.7 per 100 CKRT days, respectively. Citrate accumulation was observed in 13.3% of all patients and was associated with metabolic acidosis in 3.9%, which was not significantly different in patients with liver disease (9.3%; P = 0.2). LIMITATIONS Lack of control groups that used calcium-free dialysate and replacement solutions with RCA-CKRT. Possible overestimation of filter life from incomplete data on cause of filter failure. CONCLUSIONS Our study suggests that RCA-CKRT with calcium-containing solutions is feasible and safe in critically ill patients, including those with sepsis and liver disease.
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Affiliation(s)
- Harin Rhee
- Department of Medicine, University of California, San Diego, La Jolla, CA; Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Brendan Berenger
- Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, La Jolla, CA.
| | - Etienne Macedo
- Department of Medicine, University of California, San Diego, La Jolla, CA
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22
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Shi Y, Qin HY, Peng JM, Hu XY, Du B. Feasibility and efficacy of modified fixed citrate concentration protocol using only commercial preparations in critically ill patients: a prospective cohort study with a historical control group. BMC Anesthesiol 2021; 21:96. [PMID: 33784963 PMCID: PMC8008573 DOI: 10.1186/s12871-021-01319-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The cumbersome program and the shortage of commercial solution hindered the regular application of regional citrate anticoagulation (RCA). It is urgent to simplify the protocol using only commercial preparations. The aim of this study was to explore the feasibility and efficacy of the modified protocol for continuous veno-venous hemofiltration (CVVH) in unselected critically ill patients. METHODS A prospective cohort study was conducted in 66 patients who received a new protocol combining fixed citrate concentration with modified algorithm for supplements (i.e., fixed protocol), and compared the efficacy, safety and convenience for this group to a historical control group with a traditional protocol (n = 64), where citrate was titrated according to the circuit ionized calcium concentration (i.e., titrated protocol). The convenience was defined as the demand for monitoring test and dose adjustment of any supplement. RESULTS The filter lifespan was 63.2 ± 16.1 h in the fixed group and 51.9 ± 17.7 h in the titrated group, respectively. Kaplan-Meier survival analysis demonstrated longer circuit lifetime for fixed group (log-rank, p = 0.026). The incidence of circuit clotting was lower in the fixed protocol (15.2% vs. 29.7% in the titrated protocol, p = 0.047). Moreover, compared with the titrated group, patients with fixed protocol had less demand for monitoring test and dose adjustment of any supplement (the number of times per person per day) (3.3 [IQR 2.3-4.5] vs. 5.7 [IQR 3.3-6.9], p = 0.001 and 1.9 [IQR 0.5-2.7] vs. 6.3 [IQR 4.2-7.9], p < 0.001; respectively). No new onset bleeding complications occurred in all patients. The overall incidence of suspected citrate accumulation was 4.6% and there was no difference between the two groups (p = 0.969), yet a lower rate of metabolic alkalosis was found in the fixed group (3.0% vs. 14.1%, p = 0.024). CONCLUSIONS Our modified fixed citrate concentration protocol is feasible, safe and effective to enhance the circuit lifespan and the convenience of implementation while maintaining a similar safety when compared to the traditional protocol. Using only commercial preparations may be helpful for widespread application of RCA. TRIAL REGISTRATION Clinicaltrials.gov. NCT02663960 . Registered 26 January 2016.
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Affiliation(s)
- Yan Shi
- Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China.
| | - Han-Yu Qin
- Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Jin-Min Peng
- Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Xiao-Yun Hu
- Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Bin Du
- Department of medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
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23
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Raina R, Agrawal N, Kusumi K, Pandey A, Tibrewal A, Botsch A. A Meta-Analysis of Extracorporeal Anticoagulants in Pediatric Continuous Kidney Replacement Therapy. J Intensive Care Med 2021; 37:577-594. [PMID: 33688766 DOI: 10.1177/0885066621992751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Continuous kidney replacement therapy (CKRT) is the primary therapeutic modality utilized in hemodynamically unstable patients with severe acute kidney injury. As the circuit is extracorporeal, it poses an increased risk of blood clotting and circuit loss; frequent circuit losses affect the provider's ability to provide optimal treatment. The objective of this meta-analysis is to evaluate the safety and efficacy of the extracorporeal anticoagulants in the pediatric CKRT population. DATA SOURCES We conducted a literature search on PubMed/Medline and Embase for relevant citations. STUDY SELECTION Studies were included if they involved patients under the age of 18 years undergoing CKRT, with the use of anticoagulation (heparin, citrate, or prostacyclin) as a part of therapy. Only English articles were included in the study. DATA EXTRACTION Initial search yielded 58 articles and a total of 24 articles were included and reviewed. A meta-analysis was performed focusing on the safety and effectiveness of regional citrate anticoagulation (RCA) vs unfractionated heparin (UFH) anticoagulants in children. DATA SYNTHESIS RCA had statistically significantly longer circuit life of 50.65 hours vs. UFH of 42.10 hours. Two major adverse effects metabolic alkalosis and electrolyte imbalance seen more commonly in RCA compared to UFH. There was not a significant difference in the risk of systemic bleeding when comparing RCA vs. UFH. CONCLUSION RCA is the preferred anticoagulant over UFH due to its significantly longer circuit life, although vigilant circuit monitoring is required due to the increased risk of electrolyte disturbances. Prostacyclin was not included in the meta-analysis due to the lack of data in pediatric patients. Additional studies are needed to strengthen the study results further.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Nirav Agrawal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kirsten Kusumi
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Avisha Pandey
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Alexander Botsch
- Division of Critical Care Medicine, Summa Health, Akron, OH, USA
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24
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Szamosfalvi B, Yessayan LT, Heung M. Citrate Anticoagulation for Continuous Kidney Replacement Therapy: An Embarrassment of RICH-es. Am J Kidney Dis 2021; 78:146-150. [PMID: 33493585 DOI: 10.1053/j.ajkd.2021.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI.
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25
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Leroy C, Pereira B, Soum E, Bachelier C, Coupez E, Calvet L, Bachoumas K, Dupuis C, Souweine B, Lautrette A. Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study. Ann Intensive Care 2021; 11:13. [PMID: 33481169 PMCID: PMC7822996 DOI: 10.1186/s13613-021-00803-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is the gold standard of anticoagulation for continuous renal replacement therapy but is rarely used for intermittent hemodialysis (IHD) in ICU. Few studies assessed the safety and efficacy of RCA during IHD in ICU; however, no data are available comparing RCA to heparin anticoagulation, which are commonly used for IHD. The aim of this study was to assess the efficacy and safety of RCA compared to heparin anticoagulation during IHD. METHODS This retrospective single-center cohort study included consecutive ICU patients treated with either heparin anticoagulation (unfractionated or low-molecular-weight heparin) or RCA for IHD from July to September in 2015 and 2017. RCA was performed with citrate infusion according to blood flow and calcium infusion by diffusive influx from dialysate. Using a propensity score analysis, as the primary endpoint we assessed whether RCA improved efficacy, quantified with Kt/V from the ionic dialysance, compared to heparin anticoagulation. The secondary endpoint was safety. Exploratory analyses were performed on the changes in efficacy and safety between the implementation period (2015) and at long term (2017). RESULTS In total, 208 IHD sessions were performed in 56 patients and were compared (124 RCA and 84 heparin coagulation). There was no difference in Kt/V between RCA and heparin (0.95 ± 0.38 vs. 0.89 ± 0.32; p = 0.98). A higher number of circuit clotting (12.9% vs. 2.4%; p = 0.02) and premature interruption resulting from acute high transmembrane pressure (21% vs. 7%; p = 0.02) occurred in the RCA sessions compared to the heparin sessions. In the propensity score-matching analysis, RCA was associated with an increased risk of circuit clotting (absolute differences = 0.10, 95% CI [0.03-0.18]; p = 0.008). There was no difference in efficacy and safety between the two time periods (2015 and 2017). CONCLUSION RCA with calcium infusion by diffusive influx from dialysate for IHD was easy to implement with stable long-term efficacy and safety but did not improve efficacy and could be associated with an increased risk of circuit clotting compared to heparin anticoagulation in non-selected ICU patients. Randomized trials to determine the best anticoagulation for IHD in ICU patients should be conducted in a variety of settings.
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Affiliation(s)
- Christophe Leroy
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Edouard Soum
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Bachelier
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Elisabeth Coupez
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Laure Calvet
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Konstantinos Bachoumas
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France.
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France.
- Intensive Care Medicine, Gabriel Montpied Teaching Hospital, Intensive Care Unit, Centre Jean Perrin, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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26
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Raina R, Chakraborty R, Sethi SK, Bunchman T. Kidney Replacement Therapy in COVID-19 Induced Kidney Failure and Septic Shock: A Pediatric Continuous Renal Replacement Therapy [PCRRT] Position on Emergency Preparedness With Resource Allocation. Front Pediatr 2020; 8:413. [PMID: 32719758 PMCID: PMC7347905 DOI: 10.3389/fped.2020.00413] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023] Open
Abstract
The recent worldwide pandemic of COVID-19 has had a detrimental worldwide impact on people of all ages. Although data from China and the United States indicate that pediatric cases often have a mild course and are less severe in comparison to adults, there have been several cases of kidney failure and multisystem inflammatory syndrome reported. As such, we believe that the world should be prepared if the severity of cases begins to further increase within the pediatric population. Therefore, we provide here a position paper centered on emergency preparation with resource allocation for critical COVID-19 cases within the pediatric population, specifically where renal conditions worsen due to the onset of AKI.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General, Akron Nephrology Associates, Akron, OH, United States
- Department of Nephrology, Akron Children's Hospital, Akron, OH, United States
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General, Akron Nephrology Associates, Akron, OH, United States
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, United States
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27
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John JC, Taha S, Bunchman TE. Basics of continuous renal replacement therapy in pediatrics. Kidney Res Clin Pract 2019; 38:455-461. [PMID: 31661760 PMCID: PMC6913589 DOI: 10.23876/j.krcp.19.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 11/04/2022] Open
Abstract
In the last three decades, significant advances have been made in the care of children requiring renal replacement therapy (RRT). The move from the use of only hemodialysis and peritoneal dialysis to continuous venovenous hemofiltration with or without dialysis (continuous renal replacement therapy, CRRT) has become a mainstay in many intensive care units. The move to CRRT is the result of greater clinical experience as well as advances in equipment, solutions, vascular access, and anticoagulation. CRRT is the mainstay of dialysis in pediatric intensive care unit (PICU) for critically ill children who often have hemodynamic compromise. The advantages of this modality include the ability to promote both solute and fluid clearance in a slow continuous manner. Though data exist suggesting that approximately 25% of children in any PICU may have some degree of renal insufficiency, the true need for RRT is approximately 4% of PICU admissions. This article will review the history as well as the progress being made in the provision of this care in children.
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Affiliation(s)
- Jacob C John
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
| | - Sara Taha
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
| | - Timothy E Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
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28
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Persic V, Vajdic Trampuz B, Medved B, Pavcnik M, Ponikvar R, Gubensek J. Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation. Artif Organs 2019; 44:497-503. [PMID: 31851381 DOI: 10.1111/aor.13619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/02/2019] [Accepted: 12/12/2019] [Indexed: 01/23/2023]
Abstract
Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW.
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Affiliation(s)
- Vanja Persic
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Barbara Vajdic Trampuz
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bojan Medved
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Pavcnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Pediatric Surgery and Intensive Care, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Rafael Ponikvar
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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29
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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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30
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Lenga I, Hopman WM, O'Connell AJ, Hume F, Wei CCY. Flexitrate regional citrate anticoagulation in continuous venovenous hemodiafiltration: a retrospective analysis. BMC Nephrol 2019; 20:452. [PMID: 31805883 PMCID: PMC6896713 DOI: 10.1186/s12882-019-1648-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/28/2019] [Indexed: 12/03/2022] Open
Abstract
Background Flexitrate, an innovative regional citrate anticoagulation (RCA) protocol, was compared to traditional RCA (tRCA) and Heparin anticoagulation protocols in intensive care patients treated with continuous renal replacement therapy (CRRT). Methods A single-center, retrospective, cohort study, was done in a 26-bed intensive care unit in a large community hospital. Eighty dialysis sessions (Flexitrate = 2852 h, tRCA = 3580 h and Heparin = 2026 h), performed in 53 patients, were evaluated for filter life, RCA control, and metabolic control. Results In the Flexitrate cohort, 3.8% of filters clotted, compared to 16.9% with tRCA and 28.3% with Heparin (p < 0.001 for Flexitrate compared to either tRCA or Heparin). Filter survival was significantly improved with Flexitrate compared to tRCA (HR 0.24, p = 0.018) or Heparin (HR 0.14, p = 0.004). Anticoagulation control was superior with Flexitrate with Patient Ionized Calcium out of target a median of 16% of the time, compared to 27% for tRCA (p < 0.001). Filter Ionized Calcium was out of target a median of 6.8% of the time, compared to 23% for tRCA (p = 0.03). Flexitrate produced significantly less alkalosis, hypernatremia, and hypocalcemia than tRCA, and overall metabolic control was comparable to Heparin anticoagulation. The only adverse metabolic outcome with Flexitrate was increased hypomagnesemia. Conclusions The Flexitrate protocol extended filter life, delivered more consistent anticoagulation, and provided superior metabolic control compared to a tRCA protocol. Filter life was superior to Heparin anticoagulation, with similar metabolic control. A randomized control trial comparing these protocols is recommended.
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Affiliation(s)
- Ilan Lenga
- Division of Nephrology, Lakeridge Health, 850 Champlain Avenue, Oshawa, Ontario, L1J-8R2, Canada. .,Lakeridge Health, Oshawa, Ontario, Canada. .,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Faculty of Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Wilma M Hopman
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston General Health Research Institute, Kingston, Ontario, Canada
| | | | | | - Charles C Y Wei
- Division of Nephrology, Lakeridge Health, 850 Champlain Avenue, Oshawa, Ontario, L1J-8R2, Canada
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31
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Poh CB, Tan PC, Kam JW, Siau C, Lim NL, Yeon W, Cui HH, Ding HT, Song XY, Yan P, Chea KL, Liu JS, Chionh CY. Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy - A Safe and Effective Low-Dose Protocol. Nephrology (Carlton) 2019; 25:305-313. [PMID: 31469465 DOI: 10.1111/nep.13656] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2019] [Indexed: 01/20/2023]
Abstract
AIMS Regional citrate anticoagulation (RCA) is the preferred mode of anticoagulation for continuous renal replacement therapy (CRRT). Conventional RCA-CRRT citrate dose ranges from 3 to 5 mmol/L of blood. This study explored the effectiveness of an RCA protocol with lower citrate dose and its impact on citrate-related complications. METHODS This prospective observational study compared two RCA-CRRT protocols in the intensive care unit. RCA Protocol 1 used an initial citrate dose of 3.0 mmol/L while Protocol 2 started with 2.5 mmol/L. The citrate dose was titrated by sliding scale to target circuit-iCa 0.26-0.40 mmol/L. Calcium was re-infused post-dialyzer and titrated by protocol to target systemic-iCa 1.01-1.20 mmol/L. RESULTS Two hundred RCA-CRRT sessions were performed (81 Protocol 1; 119 Protocol 2). The median age was 65.4 years and median APACHE-II score was 23. Citrate dose for Protocol 1 was significantly higher than Protocol 2 in the first 12 h. The circuit clotting rate was similar in both arms (Protocol 1: 9.9%; Protocol 2: 9.2%; P = 0.881). With Protocol 2, circuit-iCa levels were 2.42 times more likely to be on target (P = 0.003) while the odds of hypocalcaemia was 4.67 times higher with Protocol 1 (P < 0.001). There was a wider anion gap was noted with Protocol 1, which suggests a propensity for citrate accumulation with higher citrate exposure. CONCLUSION The RCA protocol with a lower initial citrate dose of 2.5 mmol/L blood had less citrate-related complications with no loss of efficacy. A more precise RCA prescription at the start of treatment avoids unnecessary citrate exposure and improves safety.
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Affiliation(s)
- Cheng Boon Poh
- Department of Renal Medicine, Changi General Hospital, Singapore
| | - Poh Choo Tan
- Medical Intensive Care Unit, Changi General Hospital, Singapore
| | - Jia Wen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Noelle L Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Wenxiang Yeon
- Department of Renal Medicine, Changi General Hospital, Singapore
| | - Hai Hua Cui
- Medical Intensive Care Unit, Changi General Hospital, Singapore
| | - Hai Ting Ding
- Medical Intensive Care Unit, Changi General Hospital, Singapore
| | - Xiao Ying Song
- Surgical Intensive Care Unit, Changi General Hospital, Singapore
| | - Peng Yan
- Surgical Intensive Care Unit, Changi General Hospital, Singapore
| | - Kai Li Chea
- Surgical Intensive Care Unit, Changi General Hospital, Singapore
| | - Jin Shu Liu
- Surgical Intensive Care Unit, Changi General Hospital, Singapore
| | - Chang Yin Chionh
- Department of Renal Medicine, Changi General Hospital, Singapore
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Abstract
PURPOSE OF REVIEW The delivery of an effective dialysis dose in continuous renal replacement therapy (CRRT) depends on adequate anticoagulation of the extracorporeal circuit. In most patients, either systemic heparin anticoagulation (SHA) or regional citrate anticoagulation (RCA) is used. This review will outline the basics and rationale of RCA and summarize data on safety and efficacy of both techniques. RECENT FINDINGS The basic principle of RCA is to reduce the level of ionized calcium in the extracorporeal circuit via infusion of citrate. This way, effective anticoagulation restricted to the extracorporeal circuit is achieved. SHA and RCA were compared in a variety of studies. RCA significantly prolonged filter lifetime, reduced bleeding complications and provided excellent control of uremia and acid-base status. RCA was also safe in the majority of patients with impaired liver function, whereas caution must be exerted in those with severe multiorgan failure and persistent hyperlactatemia. SUMMARY RCA per se is safe and effective for anticoagulation of CRRT. Compared to SHA, efficacy of anticoagulation is improved and adverse effects are reduced. RCA can be recommended as the anticoagulation mode of choice for CRRT in most ICU patients.
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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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Naka T, Egi M, Bellomo R, Cole L, French C, Botha J, Wan L, Fealy N, Baldwin I. Commercial Low-citrate Anticoagulation Haemofiltration in High Risk Patients with Frequent Filter Clotting. Anaesth Intensive Care 2019; 33:601-8. [PMID: 16235478 DOI: 10.1177/0310057x0503300509] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study assessed the safety and efficacy of a commercial low-citrate concentration-based pre-filter replacement fluid during continuous veno-venous haemofiltration (CVVH) in patients with frequent filter clotting and high risk of bleeding. We used a commercial low-citrate fluid as pre-dilution replacement fluid during CVVH (citrate: 11 mmol/l (33 meq/l), sodium: 140 mmol/l, chloride: 108 mmol/l and potassium: 1 mmol/l). A calcium and magnesium infusion was delivered separately by central line for the maintenance of serum ionized calcium (Cai) and total magnesium (Mg). In this prospective observational study, 30 patients, 124 filters and 1,515 treatment-hours were observed. Median filter life of citrate CVVH was 9.5 hours. Filter life in the 48 hours prior to citrate CVVH was also observed. In the patients on prior non-anticoagulant CVVH (n=14) filter life increased significantly with citrate (9.5 hours vs 5 hours; P<0.0001). In patients on prior heparin CVVH (n=15), filter life was similar with citrate (10 hours vs 8 hours; P=0.68). However, in patients with prior early/frequent filter clotting despite heparin (n=11) filter life increased significantly (10 hours vs 7 hours; P=0.038). Of 411 serum Cai measurements, none showed a Cai<0.85 mmol/l and, of 84 observations, none showed a serum Mg<0.6mmol/l. One patient with sepsis and shock needed to cease citrate CVVH because of progressive ionized hypocalcaemia and increasing anion gap. No other adverse effects were observed. In selected patients, CVVH with a commercial low-citrate concentration solution as pre-filter replacement fluid and a simultaneous calcium and magnesium infusion protocol appears generally safe. Filter life was acceptable and superior to that achieved with previous treatment.
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Affiliation(s)
- T Naka
- Department of Intensive Care and Medicine (University of Melbourne), Austin Hospital, Austin Health, Victoria
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Abstract
In most of the case, regional citrate anticoagulation is using diluted citrate
around 1% depending on the types used in clinical practice. Diluted citrate is
much more safer when compared to highly concentrated citrate around 4% or even
more. In clinical practice, trisodium citrate is used in high concentration
(around 30%) as a bactericidal agent with anticoagulant properties for locking
deep venous catheters used in hemodialysis (HD; close to 25–30% of
citrate). In this review article, buffer and anticoagulant potential of citrate
are discussed during renal replacement therapy in critically ill patients with
particular focus on the practical approach at the bedside.
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Al-Ayed T, Rahman NU, Alturki A, Aljofan F. Outcome of continuous renal replacement therapy in critically ill children: a retrospective cohort study. Ann Saudi Med 2018; 38:260-268. [PMID: 30078024 PMCID: PMC6086670 DOI: 10.5144/0256-4947.2018.260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) has become the preferred mode of dialysis to support critically ill children with acute kidney injury. However, there are limited pediatric data on CRRT use, especially in our region. OBJECTIVE Determine the outcome of CRRT among critically ill children. DESIGN Retrospective cohort study. SETTING Pediatric intensive care unit. PATIENTS AND METHODS The study included critically ill children 1-14 years of age who underwent CRRT from July 2009 to June 2015. We report the underlying diagnosis, demographics, indications and modality of CRRT, and associated risk factors. Statistical analyses were used to identify risk factors associated with mortality. MAIN OUTCOME MEASURES Mortality and associated risk factors with use of CRRT. SAMPLE SIZE 96 RESULTS: The mean age was 6.0 (standard deviation, 4.4) years, with a male preponderance in the age group from 1-10 years which comprised almost 60% of the study group. The most common primary diagnoses were malignancies [37.5% (36/96)] followed by primary renal diseases [19.8% (19/96)], and immunodeficiency [16.7% (16/96)]. The most common indication for CRRT was fluid overload [67.2% (65/96)] followed by tumor lysis syndrome [18.8%(18/96)], and metabolic encephalopathy [9.4%(9/96)]. The median length of CRRT was 66 hours (IQR, 35.5-161.4), with a median average circuit life of 30.9 hours (IQR, 16.4-45.0). The most common CRRT catheter site was the internal jugular vein [77.1% (74/96)], followed by the femoral vein [18.8%(18/96)] with continuous venovenous hemodiafiltration [82.3%(79/96)] being the most common CRRT modality used. The mortality rate among critically ill children requiring CRRT was 50% (48/96). There was an increased mortality rate among children with hematological diseases (100%, 10/10), immunodeficiency (86.6%, 13/16) and in children who had undergone stem cell transplantation (90.0%, 27/30), with the least mortality in primary renal disease (15.8% (3/19). We identified septic shock and use of inotropic support as being independently associated with mortality in a multivariate analysis. CONCLUSION The overall mortality rate among critically ill children who un.derwent CRRT was 50% with significantly increased mortality among patients with hematological diseases, immunodeficiency, and in children who had undergone stem cell transplantation. Septic shock and use of inotropic support were associated with mortality. LIMITATIONS Retrospective and single center data that is not generalizable. CONFLICT OF INTEREST None.
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Affiliation(s)
- Tareq Al-Ayed
- Dr. Tareq Al-Ayed, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +96614427763 F: +96614427784, , ORCID: http://orcid.org/0000-0001-7525-3529
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Schmitz M, Joannidis M, Czock D, John S, Jörres A, Klein SJ, Oppert M, Schwenger V, Kielstein J, Zarbock A, Kindgen-Milles D, Willam C. [Regional citrate anticoagulation in renal replacement therapy in the intensive care station : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:377-383. [PMID: 29737362 DOI: 10.1007/s00063-018-0445-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) in continuous renal replacement therapy can effectively anticoagulate dialysis circuits without having adverse effects on systemic heparin application. In particular, in continuous renal replacement therapy RCA is well established and represents a safe procedure with longer filter lifetimes and fewer bleeding complications. OBJECTIVES To provide guidance on the indications, advantages and disadvantages, and use of RCA, current recommendations from the renal section 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 in this paper are based on the current KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, other published guidelines and protocols as well as the expert knowledge and clinical experience of the authors. RESULTS The use of commercially available machines with coupled pumps and integrated safety features, effective personal training and standardized protocols for clinical usage (SOP) is particularly important for the safe clinical use of RCA in renal replacement therapy. Contrary to previous recommendations, even liver failure or shock with lactic acidosis may no longer be an absolute contra-indication for RCA. However, these particular patients have to be carefully monitored for signs of citrate accumulation.
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Affiliation(s)
- M Schmitz
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Deutschland.
| | - M Joannidis
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität (PMU) Nürnberg, Universität Erlangen-Nürnberg, Klinikum Nürnberg-Süd, Nürnberg, Deutschland
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - S J Klein
- Gemeinsame Einrichtung internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - J Kielstein
- Medizinische Klinik V, Nephrologie, Rheumatologie, Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - C Willam
- Medizinische Klinik 4, Nephrologie und Hypertensiologie, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland
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Costa E Silva VT, Caires RA, Bezerra JS, Costalonga EC, Oliveira APL, Oliveira Coelho F, Fukushima JT, Soares CM, Oikawa L, Hajjar LA, Burdmann EA. Use of regional citrate anticoagulation for continuous venovenous hemodialysis in critically ill cancer patients with acute kidney injury. J Crit Care 2018; 47:302-309. [PMID: 29859647 DOI: 10.1016/j.jcrc.2018.04.006] [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: 12/22/2017] [Revised: 03/27/2018] [Accepted: 04/04/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE This study aimed to evaluate the safety and efficacy of a regional citrate anticoagulation (RCA) protocol for continuous venovenous hemodialysis (CVVHD) in cancer patients with acute kidney injury (AKI) in the intensive care unit (ICU) setting. MATERIAL AND METHODS One hundred twenty two consecutive ICU cancer patients with AKI treated with citrate-based CVVHD were prospectively evaluated in this prospective observational study. RESULTS A total of 7198 h of CVVHD therapy (250 filters) were performed. Patients were 61.3 ± 15.7 years old, 78% had solid cancer and the main AKI cause was sepsis (50%). The in-hospital mortality was 78.7%. Systemic ionized calcium (SCai) was 4.35 (4.10-4.60) mg/dL, severe hypocalcemia (SCai <3.6 mg/dL) was observed in 4.3% of procedures and post-filter ionized calcium was 1.60 (1.40-1.80) mg/dL. Median filter patency was 24.8 (11-43) hours. Factors related to filter clotting were: no tumor evidence (OR 0.44, CI 0.18-0.99); genitourinary tumor (OR 1.83, CI 1.18-2.81); platelets number (each 10,000/mm3) (OR 1.02, CI 1.00-1.04); International Normatized Ratio (INR) (OR 0.59, CI 0.41-0.85) and citrate dose (each 10 mL/h) (OR 0.88, CI 0.82-0.95). CONCLUSION Filter patency was relatively short and clotting was associated with active cancer disease, genitourinary tumor, lower citrate dose and lower INR.
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Affiliation(s)
- Verônica Torres Costa E Silva
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil.
| | - Renato Antunes Caires
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Juliana Silva Bezerra
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Elerson C Costalonga
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ana Paula Leandro Oliveira
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Fernanda Oliveira Coelho
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Julia T Fukushima
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Cilene Muniz Soares
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Luciane Oikawa
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit Department, Sao Paulo State Cancer Institute, University of Sao Paulo School Medical School, Sao Paulo, Sao Paulo, Brazil
| | - Emmanuel A Burdmann
- Nephrology Division, Sao Paulo State Cancer Institute, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil; LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
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Treatment dose and the elimination rates of electrolytes, vitamins, and trace elements during continuous veno-venous hemodialysis (CVVHD). Int Urol Nephrol 2018; 50:1143-1149. [PMID: 29611144 DOI: 10.1007/s11255-018-1856-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION During continuous renal replacement therapy, achievement of recommended treatment dose is important. However, relevant substrate loss may occur and recommended nutrition during critical illness could not be sufficient for higher dialysis doses. We investigated the correlation of dialysis dose and substrate loss for a broad range of dialysis doses. METHODS Forty critically ill patients with acute kidney injury undergoing citrate CVVHD were included in this prospective study. Three different corresponding blood flow (BF) and dialysate flow (DF) rates were applied (BF/DF: 100 ml/min, 2000 ml/h; 80 ml/min, 1500 ml/h; 120 ml/min, 2500 ml/h). Delivered effluent flow rate (DEFR) was calculated and correlated with losses of vitamins, electrolytes, and trace elements during recommended nutritional supplementation. RESULTS For folic acid, vitamin B12, zinc, inorganic phosphate, and magnesium, no correlation of losses and DEFR was detected. For ionized calcium, a correlation was observed and additional substitution was required. CONCLUSION Clinically relevant loss of folic acid, vitamin B12, zinc, inorganic phosphate, and magnesium was not observed for differently used dialysis doses of CVVHD, and the loss was covered sufficiently by daily recommended nutritional supplementation. Increased loss of ionized calcium for higher dialysis doses occurred during citrate CVVHD. Therefore, a strict protocol must maintain calcium homeostasis to avoid calcium depletion.
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Kleger GR, FäSsler E. Can Circuit Lifetime be a Quality Indicator in Continuous Renal Replacement Therapy in the Critically Ill? Int J Artif Organs 2018; 33:139-46. [DOI: 10.1177/039139881003300302] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2010] [Indexed: 11/17/2022]
Abstract
Purpose Continuous renal replacement therapy (CRRT) is frequently used in critically ill patients with acute renal failure and sepsis. Frequent circuit changes increase nursing workload, blood loss and costs, and also compromise achievement of the filtration rate goal. Circuit downtime is the most important factor that compromises the cumulative filtration goal. Methods We used continuous venovenous hemodiafiltration (Prismaflex®, Gambro, Meyzieu Cedex, France) in our 12-bed medical intensive care unit (ICU). Circuit lifetimes, indication to start CRRT, anticoagulation protocol, reason for circuit change, and location of the vascular access were prospectively documented for 12 months in consecutive patients. Unfractionated heparin was the first choice for anticoagulation. No anticoagulation was used in patients with severe coagulation abnormalities or hepatic failure; regional citrate-based anticoagulation (CBA) was used in patients with recurrent circuit clotting or with bleeding predisposition. Our aim was to assess the suitability of circuit lifetime as a quality indicator, evaluated by survival analysis. Results Median circuit lifetime was significantly longer for CBA (log rank χ2=8.08; p=0.018). This is consistent with the literature. There were no differences in vascular access site, proportion of sepsis, or vasopressor dependency between the three anticoagulation groups. Conclusions In addition to monitoring the complication rate, the evaluation of circuit lifetime using survival analysis stratified by anticoagulation strategy is a simple and feasible means of assessing the quality of CRRT in the ICU.
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Affiliation(s)
- Gian-Reto Kleger
- Medical Intensive Care Unit, St. Gallen Canton Hospital, St. Gallen - Switzerland
| | - Edith FäSsler
- Medical Intensive Care Unit, St. Gallen Canton Hospital, St. Gallen - Switzerland
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Van der Voort PHJ, Postma SR, Kingma WP, Boerma EC, Van Roon EN. Safety of Citrate Based Hemofiltration in Critically Ill Patients at High Risk for Bleeding: A Comparison with Nadroparin. Int J Artif Organs 2018; 29:559-63. [PMID: 16841283 DOI: 10.1177/039139880602900603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose To study the incidence and severity of bleeding in high risk critically ill patients during high volume, citrate based continuous veno-venous hemofiltration (CVVH). Design A prospective 1-year observational cohort study comparing citrate based CVVH with nadroparin based CVVH. Procedures Critically ill patients with multiple organ dysfunction and in need of CVVH were observed for bleeding complications during their CVVH sessions. Pre-defined criteria determined that patients were treated with citrate based CVVH in case of active bleeding or increased risk for bleeding. Otherwise nadroparin was used as anticoagulant. Statistical and Outcome Methods The incidence of bleeding complications, the number of transfused blood cell concentrates and the filter-run-time were recorded. Analyses were made by non-parametric tests. Main Findings Fifty-five patients received 272 CVVH sessions. In the citrate group 14.8% experienced a bleeding complication compared to 25% in the nadroparin group (p=0.04). The number of transfused red blood cell concentrates was not different between groups. The nadroparin group had a longer filter run time (median 31.5 hours versus 22.5 hours, p=0.0001). Conclusions In high risk critically ill patients citrate based anticoagulation for CVVH is safe in terms of bleeding complications and transfusion requirements.
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Affiliation(s)
- P H J Van der Voort
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden - The Netherlands.
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Naka T, Egi M, Bellomo R, Cole L, French C, Wan L, Fealy N, Baldwin I. Low-dose Citrate Continuous Veno-venous Hemofiltration (CVVH) and Acid-base Balance. Int J Artif Organs 2018; 28:222-8. [PMID: 15818544 DOI: 10.1177/039139880502800306] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To evaluate the acid-base effect of low-dose regional citrate anticoagulation (RCA) during continuous veno-venous hemofiltration (CVVH). Design Prospective observational study. Setting ICUs of tertiary public and private hospitals. Subjects Thirty critically ill patients with acute renal failure at risk of bleeding or with a major contraindication to heparin-CVVH and/or short filter life. Methods We used a commercial citrate-based fluid (11 mmol/L, sodium: 140 mmol/L, chloride: 108 mmol/L and 1 mol/L of potassium) as pre-dilution replacement fluid during CVVH. Further potassium was added according to serum potassium levels. We measured all relevant variables for acid-base analysis according to the Stewart-Figge methodology. Results Before treatment, study patients had a slight metabolic acidosis, which worsened over 6 hours of RCA-CVVH (pH from 7.39 to 7.38, p<0.005; bicarbonate from 23.2 to 21.6 mmol/L, p<0.0001 and base excess from −2.0 to −3.0 mEq/L, p<0.0001) due to a significant increase in SIG (from 5.8 to 6.6 mEq/L, p<0.05) and a decrease in SIDa (from 37.5 to 36.6 mEq/L, p<0.05). These acidifying effects were attenuated by hypoalbuminemia and a decrease in lactate (from 1.48 to 1.34 mmol/L, p<0.005) and did not lead to progressive acidosis. On cessation of treatment, this acidifying effect rapidly self-corrected within six hours. Conclusions Low dose RCA-CVVH induces a mild acidosis secondary to an increased strong ion gap and decreased SIDa which fully self-corrects at cessation of therapy. Clinicians need to be aware of these effects to correctly interpret changes in acid-base status in such patients.
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Affiliation(s)
- T Naka
- Department of Intensive Care and Department of Medicine, Austin Hospital and Melbourne University, Melbourne, Australia
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Kindgen-Milles D, Amman J, Kleinekofort W, Morgera S. Treatment of Metabolic Alkalosis during Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Int J Artif Organs 2018; 31:363-6. [DOI: 10.1177/039139880803100414] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of citrate as an anticoagulant in continuous renal replacement therapy is an effective method to achieve regional anticoagulation of the extracorporeal blood circuit and to avoid systemic anticoagulation. This allows bleeding complications to be reduced and filter life time to be prolonged. However, citrate enters the systemic circulation and is metabolized in the liver to bicarbonate, causing metabolic alkalosis in some patients. In this case report, we discuss therapeutic interventions to control the acid-base status and to restore normal pH during continuous citrate hemodialysis.
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Affiliation(s)
- D. Kindgen-Milles
- University Hospital Düsseldorf, Department of Anesthesiology, Heinrich Heine University Düsseldorf, Düsseldorf - Germany
| | - J. Amman
- University Hospital Düsseldorf, Department of Anesthesiology, Heinrich Heine University Düsseldorf, Düsseldorf - Germany
| | - W. Kleinekofort
- Department of Physical Technologies, University of Applied Sciences Wiesbaden, Wiesbaden - Germany
| | - S. Morgera
- University Hospital Chiarité Campus Mitte, Department of Nephrology, Humboldt University Berlin, Berlin - Germany
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Cubattoli L, Teruzzi M, Cormio M, Lampati L, Pesenti A. Citrate Anticoagulation during CVVH in High Risk Bleeding Patients. Int J Artif Organs 2018; 30:244-52. [PMID: 17417764 DOI: 10.1177/039139880703000310] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Regional citrate anticoagulation (RCA) is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients with contraindications to heparin. Its use has been very limited, possibly because of the need for special infusion solutions and difficult monitoring of the metabolic effects. Objective To investigate the safety and the feasibility of an RCA method for continuous veno-venous hemofiltration (CVVH) using commercially available replacement fluid. Methods We evaluated 11 patients at high risk of bleeding, requiring CVVH. RCA was performed using commercially available replacement fluid solutions to maintain adequate acid-base balance. We adjusted the rate of citrate infusion to achieve a post-filter ionized calcium concentration [iCa] <0.4 mmol/L when blood flow was <250 ml/min, or <0.6 mmol/L when blood flow was >250 ml/min. When needed, we infused calcium gluconate to maintain systemic plasma [iCa] within the normal range. Results Twenty-nine filters ran for a total of 965.5 h. Average filter life was 33.6±20.5 h. Asymptomatic hypocalcemia was detected in 6.9% of all samples. No [iCa] values <0.9 mmol/L were observed. Hypercalcemia (1.39±0.05 mmol/L) occurred in 2.5% of all samples. We observed hypernatremia (threshold 153 mmol/L) and alkalosis (threshold 7.51) in only 9.3% and 9.4% respectively of all samples, mostly concomitantly. No patient showed any signs of citrate toxicity. Conclusions: We developed a protocol for RCA during CVVH using commercially available replacement fluid that proved safe, flexible and applicable in an Intensive Care Unit (ICU) setting.
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Affiliation(s)
- L Cubattoli
- Department of Anesthesia and Intensive Care, University of Milan-Bicocca, San Gerardo Hospital, Via Donizetti 106, 20052 Monza, Italy.
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Klingele M, Stadler T, Fliser D, Speer T, Groesdonk HV, Raddatz A. Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:294. [PMID: 29187232 PMCID: PMC5707786 DOI: 10.1186/s13054-017-1870-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/23/2017] [Indexed: 11/10/2022]
Abstract
Background As of 2009, anticoagulation with citrate was standard practice in continuous renal replacement therapy (CRRT) for critically ill patients at the University Medical Centre of Saarland, Germany. Partial hepatic metabolism of citrate means accumulation may occur during CRRT in critically ill patients with impaired liver function. The aim of this study was to evaluate the actual influence of hepatic function on citrate-associated complications during long-term CRRT. Methods In a retrospective study conducted between January 2009 and November 2012, all cases of dialysis therapy performed in the interdisciplinary surgical intensive care unit were analysed. Inclusion criteria were CRRT and regional anticoagulation with citrate, pronounced liver dysfunction, and pathologically reduced indocyanine green plasma disappearance rate (ICG-PDR). Results A total of 1339 CRRTs were performed in 69 critically ill patients with liver failure. At admission, the mean Model for End-stage Liver Disease score was 19.2, and the mean ICG-PDR was 9.8%. Eight patients were treated with liver replacement therapy, and 30 underwent transplants. The mortality rate was 40%. The mean duration of dialysis was 19.4 days, and the circuit patency was 62.2 h. Accumulation of citrate was detected indirectly by total serum calcium/ionised serum calcium (tCa/iCa) ratio > 2.4. This was noted in 16 patients (23.2%). Dialysis had not to be discontinued for metabolic disorder or accumulation of citrate in any case. In 26% of cases, metabolic alkalosis occurred with pH > 7.5. Interestingly, no correlation between citrate accumulation and liver function parameters was detected. Moreover, most standard laboratory liver function parameters showed poor predictive capabilities for accumulation of citrate. Conclusions Our findings indicate that extra-hepatic metabolism of citrate seems to exist, avoiding in most cases citrate accumulation in critically ill patients despite impaired liver function. Because the citric acid cycle is oxygen-dependent, disturbed microcirculation would result in inadequate citrate metabolism. Raising the tCa/iCa ratio would therefore be an indicator of severity of illness and mortality rather than of liver failure. However, further studies are warranted for confirmation.
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Affiliation(s)
- Matthias Klingele
- Department of Internal Medicine - Nephrology and Hypertension, Saarland University Medical Centre, Homburg/Saar, Germany. .,Departments of Nephrology and Internal Medicine, Hochtaunus-Kliniken, Zeppelinstrasse 20, D-61352, Bad Homburg, Germany. .,Departments of Nephrology and Internal Medicine, Hochtaunus-Kliniken, 61250, Usingen, Germany.
| | - Theresa Stadler
- Department of Internal Medicine - Nephrology and Hypertension, Saarland University Medical Centre, Homburg/Saar, Germany
| | - Danilo Fliser
- Department of Internal Medicine - Nephrology and Hypertension, Saarland University Medical Centre, Homburg/Saar, Germany
| | - Timo Speer
- Department of Internal Medicine - Nephrology and Hypertension, Saarland University Medical Centre, Homburg/Saar, Germany
| | - Heinrich V Groesdonk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, Homburg/Saar, Germany
| | - Alexander Raddatz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Centre, Homburg/Saar, Germany
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Francey T, Schweighauser A. Regional Citrate Anticoagulation for Intermittent Hemodialysis in Dogs. J Vet Intern Med 2017; 32:147-156. [PMID: 29171099 PMCID: PMC5787180 DOI: 10.1111/jvim.14867] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/17/2017] [Accepted: 10/11/2017] [Indexed: 12/05/2022] Open
Abstract
Background The traditional systemic heparinization used for anticoagulation in extracorporeal therapies may cause fatal complications in animals at risk of bleeding. Hypothesis/Objectives To develop and validate a protocol of regional citrate anticoagulation (RCA) for intermittent hemodialysis in dogs. Animals A total of 172 dogs treated with hemodialysis for acute kidney injury. Methods In vitro titration was performed, adding trisodium citrate and calcium chloride to heparinized canine blood. A tentative protocol was used first in 66 treatments with additional heparinization and subsequently in 518 heparin‐free treatments. Safety and adequacy of RCA were assessed based on clinical and laboratory monitoring, dialyzer pressure gradient, treatment completion, and visual scoring of the extracorporeal circuit. Results Addition of 1 mmol/L citrate to heparinized blood decreased the ionized calcium concentration by 0.23 mmol/L (95% confidence interval [CI], 0.16–0.30) and 1 mmol/L calcium increased it by 0.62 mmol/L (95% CI, 0.45–0.79). Heparin‐free treatments were initiated with infusion of trisodium citrate (102 mmol/L) at 2.55 mmol/L blood and calcium chloride (340 mmol/L) at 0.85 mmol/L. Citrate and calcium administrations were adjusted in 27 and 34% of the treatments, respectively. Overall, anticoagulation was satisfactory in 92% of the treatments, with expected azotemia reduction in 95% (urea) and 86% (creatinine), stable dialyzer pressure gradient in 82%, and clean extracorporeal circuits in 92% of the treatments. Eighteen treatments (3.5%) were discontinued prematurely, 9 because of clotting and 9 for reasons unrelated to the RCA procedure. Conclusions and Clinical Importance Regional citrate anticoagulation allows safe and efficient heparin‐free hemodialysis in dogs at risk of bleeding.
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Affiliation(s)
- T Francey
- Division of Small Animal Internal Medicine, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - A Schweighauser
- Division of Small Animal Internal Medicine, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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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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Buturovic-Ponikvar J. Is Regional Citrate Anticoagulation the Future of Hemodialysis? Ther Apher Dial 2017; 20:234-9. [PMID: 27312907 DOI: 10.1111/1744-9987.12429] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022]
Abstract
Citrate has many characteristics of the ideal anticoagulant for hemodialysis. In addition to immediate and complete anticoagulation in the dialysis circuit, citrate has important effects beyond anticoagulation, mainly in reducing inflammatory response induced by hemodialysis. Citrate has already become the standard anticoagulant in acute kidney injury requiring continuous renal replacement therapy (CRRT), both for adults and children, with the citrate module being a part of modern CRRT monitors. Although the citrate module is not yet available for intermittent hemodialysis, precise infusion pumps, point-of-care ionometers and high citrate clearance from high flux dialyzers increase safety while reducing the risk of metabolic complications, both in adult and pediatric patients. Slovenia has a long tradition, high volume and expansion of citrate use in hemodialysis, including long-term citrate anticoagulation in selected patients. At the Department of Nephrology, University Medical Centre Ljubljana, more than 10 000 citrate procedures were performed in 2015. We believe that regional citrate anticoagulation may replace heparin as the main anticoagulant for intermittent hemodialysis in the not so distant future.
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Affiliation(s)
- Jadranka Buturovic-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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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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Datzmann T, Träger K, Reinelt H, von Freyberg P. Elimination Rates of Electrolytes, Vitamins, and Trace Elements during Continuous Renal Replacement Therapy with Citrate Continuous Veno-Venous Hemodialysis: Influence of Filter Lifetime. Blood Purif 2017; 44:210-216. [PMID: 28787723 DOI: 10.1159/000477454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/12/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS During continuous renal replacement therapy, relevant losses of nutritional substrates, vitamins, and trace elements via the filter may occur. We investigated filter lifetime efficiency during a 72-h treatment period. METHODS This prospective study included 40 patients undergoing citrate continuous veno-venous hemodialysis (CVVHD). The elimination rates were measured at 24, 48, and 72 h. To assess the influence of filter lifetime, we determined substrate loss every 24 h over a 72-h interval. RESULTS Filter lifetime did not affect the loss of ionized calcium, inorganic phosphate, magnesium, zinc, folic acid, and vitamin B12. Nevertheless, we did observe clinically significant loss of ionized calcium and inorganic phosphate during CVVHD that required supplementation. CONCLUSIONS CVVHD leads to significant loss of ionized calcium and inorganic phosphate that is independent of the filter lifetime.
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Affiliation(s)
- Thomas Datzmann
- Department of Cardiac Anesthesiology, University Hospital Ulm, Ulm, Germany
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