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Mariano F, Greco' D, Depetris N, Mella A, Sciarrillo A, Stella M, Berardino M, Risso D, Gambino R, Biancone L. CytoSorb® in burn patients with septic shock and Acute Kidney Injury on Continuous Kidney Replacement Therapy is associated with improved clinical outcome and survival. Burns 2024; 50:1213-1222. [PMID: 38494395 DOI: 10.1016/j.burns.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/01/2024] [Accepted: 02/27/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND In burn patients, septic shock and acute kidney injury (AKI) with use of continuous renal replacement therapy (CRRT) severely increase morbidity and mortality. Sorbent therapies could be an adjunctive therapy to address the underlying metabolic changes in inflammatory and anti-inflammatory cytokines dysregulated production. METHODS A retrospectively observational study of 35 severe burn patients admitted to the Burn Center (Turin, Italy, from January 2017 to December 2022), who underwent CRRT for AKI-associated septic shock. Out of 35 patients, 11 were treated with CytoSorb® as adjunctive therapy to CRRT (Sorbent group) and 24 patients only with CRRT (Control group). RESULTS The application of CytoSorb® took place in a very dispersed way. Out of 11 patients, 7 started the CRRT together with the sorbent application. The patients of the sorbent group exhibited a significant reduction in norepinephrine use compared to that of the control group. A clinical improvement over the first 4 days of Cytosorb® was observed in both survivors and no survivors of the sorbent group, with significant norepinephrine decreased use on day 4 compared to day 1. In-hospital mortality was 45.4% and 70.8% in the sorbent and control group, respectively, and significantly better at Kaplan-Meier survival analysis at 270 days (p = 0.0445). In both groups, all survivor patients recovered renal function at discharge, whereas no survivors did not. CONCLUSIONS Adjunctive treatment with CytoSorb® for burn patients with AKI-CRRT and septic shock poorly responsive to standard therapy led to a significant clinical improvement, and was associated with a lower mortality rate compared to CRRT alone.
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Affiliation(s)
- Filippo Mariano
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Domenico Greco'
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy
| | - Nadia Depetris
- Anesthesia and Intensive Care 3, Department of Anesthesia and Intensive Care, City of Health and Science, CTO Hospital, Turin, Italy
| | - Alberto Mella
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Sciarrillo
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Maurizio Stella
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Maurizio Berardino
- Anesthesia and Intensive Care 3, Department of Anesthesia and Intensive Care, City of Health and Science, CTO Hospital, Turin, Italy
| | - Daniela Risso
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Roberto Gambino
- Department of Medical Sciences, University of Turin, Turin, Italy; Laboratory of Diabetology and Metabolism, University of Turin, Italy
| | - Luigi Biancone
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
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Israni A, Goldfarb DS. Let's stop talking about 'citrate toxicity'. Curr Opin Nephrol Hypertens 2024; 33:181-185. [PMID: 37962170 DOI: 10.1097/mnh.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is a vital medical intervention used in critically ill patients with acute kidney injury (AKI). One of the key components of adequate clearance with CRRT is the use of anticoagulants to prevent clotting of the extracorporeal circuit. Regional citrate anticoagulation is the most often recommended modality. The term 'citrate toxicity' is used to describe potential adverse effects of accumulation of citrate and subsequent hypocalcemia. However, citrate is itself not inherently toxic. The term and diagnosis of citrate toxicity are questioned in this review. RECENT FINDINGS Citrate is being increasingly used for regional anticoagulation of the CRRT circuit. Citrate accumulation is infrequent and can cause hypocalcemia and metabolic alkalosis, which are potential adverse effects. Citrate itself, however, is not a toxic molecule. The term 'citrate toxicity' has been used to denote hypocalcemia and metabolic acidosis. However, citrate administration is well known to cause systemic and urinary alkalinization and under certain circumstances, metabolic alkalosis, but is not associated itself with any 'toxic' effects.We review the existing literature and debunk the perceived toxicity of citrate. We delve into the metabolism and clearance of citrate and question current data suggesting metabolic acidosis occurs as the result of citrate accumulation. SUMMARY In conclusion, this article calls into question prevailing concerns about 'citrate toxicity'. We emphasize the need for a more nuanced understanding of its safety profile. We recommend discarding the term 'citrate toxicity' in favor of another frequently used, but more meaningful term: 'citrate accumulation'.
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Affiliation(s)
- Avantika Israni
- Nephrology Division, NYU Grossman School of Medicine and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA
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Xinping Z, Jie H, Zhenya Y, Desheng Z, Xiong Z. Citrate anticoagulation in plasma exchange followed by continuous renal replacement therapy in critically ill children. Int J Artif Organs 2024; 47:85-95. [PMID: 38229209 DOI: 10.1177/03913988231223375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate the effectiveness and safety of regional citrate-anticoagulated (RCA) plasma exchange (PE) and whether citrate-related metabolic disorders can be improved by sequential RCA continuous renal replacement therapy (CRRT). METHODS This retrospective, single-center observational study included 79 critically ill children requiring PE followed by CRRT (June 2018 to June 2021) at the Pediatric Intensive Care Unit of Hunan Children's Hospital, China. Patients were divided into the RCA-PE (n = 30) and systemic heparin anticoagulation (SHA-PE) (n = 49) groups. Filter level comparison post-PE assessed RCA-PE efficacy, and metabolic changes occurring pre- and post-PE and CRRT were used to evaluate the effect of CRRT on RCA-based anticoagulation safety. RESULTS The RCA-PE group had a better overall filter performance than the SHA-PE group. Two hours after PE, pH and HCO₃- levels increased more significantly for the RCA-PE than the SHA-PE group. The RCA-PE incidence of metabolic alkalosis was 48.3%, higher by 4.2% (p < 0.001) compared to the SHA-PE group. In the RCA-PE group, pH and HCO₃- decreased significantly 4 h after CRRT; the metabolic alkalosis caused by RCA-PE decreased to 13.8% (p = 0.005). No significant difference in pH, HCO₃-, and metabolic alkalosis incidence was observed between the two groups 4 h after CRRT. CONCLUSIONS The overall filtration performance of RCA-PE is superior to that of SHA-PE followed by CRRT. The metabolic complications associated with RCA-PE are mainly metabolic alkalosis that can be improved by using CRRT after RCA-PE and this is a better alternative for anticoagulation during PE in critically ill children.
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Affiliation(s)
- Zhang Xinping
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - He Jie
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Yao Zhenya
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhu Desheng
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhou Xiong
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, Hunan, China
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Hong Q, Chen S, He Y, Chen J, Zhang P. Construction and validation of a prediction model for the risk of citrate accumulation in patients with hepatic insufficiency receiving continuous renal replacement therapy with citrate anticoagulation. BMC Nephrol 2024; 25:27. [PMID: 38254020 PMCID: PMC10804492 DOI: 10.1186/s12882-024-03462-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND To construct and validate a prediction model of the risk of citrate accumulation in patients with hepatic dysfunction receiving continuous renal replacement therapy with regional citrate anticoagulation (RCA-CRRT), which reduces the risk of citrate accumulation. METHODS All patients who received RCA-CRRT from 2021 to 2022 and were hospitalized in the First Affiliated Hospital of Zhejiang University were considered for study participation. Logistic regression analysis was used to identify the risk factors for citrate accumulation, based on which a nomogram model was constructed and validated in the validation group. RESULTS Six factors were finally identified, from which a nomogram was created to predict the risk of citrate accumulation. The area under the curve of the prediction model was 0.814 in the training group and 0.819 in the validation group, and the model showed acceptable agreement between the actual and predicted probabilities. Decision curve analysis also demonstrated that the model was clinically useful. CONCLUSIONS The model constructed from six factors reliably predicted the risk of citrate accumulation in patients with hepatic insufficiency who received RCA-CRRT.
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Affiliation(s)
- Quxia Hong
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
- Department of Nephrology, Tiantai People's Hospital, Taizhou, Zhejiang, China
| | - Siyu Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Yongchun He
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Jianghua Chen
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China
| | - Ping Zhang
- Kidney Disease Center, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China.
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang, China.
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Liu D, Zhao J, Xia H, Dong S, Yan S, Zhuang Y, Chen Y, Peng H. Nafamostat mesylate versus regional citrate anticoagulation for continuous renal replacement therapy in patients at high risk of bleeding: a retrospective single-center study. Eur J Med Res 2024; 29:72. [PMID: 38245802 PMCID: PMC10799389 DOI: 10.1186/s40001-024-01660-7] [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: 11/14/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
PURPOSE The choice of continuous renal replacement therapy (CRRT) anticoagulation program for patients at high risk of bleeding has always been a complex problem in clinical practice. Clinical regimens include regional citrate anticoagulation (RCA) and nafamostat mesylate (NM). This study aimed to evaluate the efficacy and safety of these two anticoagulants for CRRT in patients at high risk of bleeding to guide their clinical use better. PATIENTS AND METHODS Between January 2021 and December 2022, 307 patients were screened for this study. Forty-six patients were finally enrolled: 22 in the regional citrate anticoagulation group and 24 in the nafamostat mesylate group. We collected patients' baseline characteristics, laboratory indicators before CRRT, and CRRT-related data. We then performed a statistical analysis of the data from both groups of patients. RESULTS In our study, the baseline characteristics did not differ significantly between the two groups; the baseline laboratory indicators before CRRT of patients in the two groups were not significantly different. The duration of CRRT was 600 min in the regional citrate anticoagulation (RCA) group, 615 min in the nafamostat mesylate (NM) group; the success rate was 90.7% in the RCA group, and 85.6% in the NM group, the anticoagulant efficacy between the two groups was comparable. There was no significant difference in the safety of anticoagulation between the two groups. We used Generalized Estimating Equations (GEE) to test whether different anticoagulation methods significantly affected the success rate of CRRT and found no statistical difference between RCA and NM. CONCLUSION Our study suggests that nafamostat mesylate's anticoagulant efficacy and safety are not inferior to regional citrate anticoagulation for continuous renal replacement therapy in patients at high risk of bleeding.
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Affiliation(s)
- Dan Liu
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Jian Zhao
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Hui Xia
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Shi Dong
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Songjuan Yan
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Yugang Zhuang
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China
| | - Yuanzhuo Chen
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China.
| | - Hu Peng
- Department of Emergency, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchang Middle Road, Jingan District, Shanghai, People's Republic of China.
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Assefi M, Leurent A, Blanchard F, Quemeneur C, Deransy R, Monsel A, Constantin JM. Impact of increasing post-filter ionized calcium target on filter lifespan in renal replacement therapy with regional citrate anticoagulation: A before-and-after study. J Crit Care 2023; 78:154364. [PMID: 37379797 DOI: 10.1016/j.jcrc.2023.154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Regional citrate anticoagulation (RCA) is the recommended method for anticoagulation in continuous renal replacement therapy (CRRT). However, the optimal post-filter ionized calcium (iCa) target level remains unclear. This study aims to assess the effect of increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L on filter lifespan until clotting during RCA-CRRT. METHODS This before-and-after single-center study included patients who underwent RCA-CRRT sessions without systemic anticoagulation during two periods. The first period included patients with a post-filter iCa target between 0.25 and 0.35 mmol/L, while the second period included those with a target between 0.30 and 0.40 mmol/L. The primary outcome was filter lifespan until clotting. RESULTS A total of 1037 CRRT sessions were analyzed, with 610 sessions in the first period and 427 sessions in the second period. After adjusting for confounding factors, there was no significant difference in filter lifespan until clotting between the two groups (hazard ratio, 1.020 [0.703; 1.481]; p = 0.92). CONCLUSION Increasing the post-filter iCa target level from 0.25-0.35 mmol/L to 0.30-0.40 mmol/L during RCA-CRRT does not reduce filter lifespan until clotting and may decrease unnecessary citrate exposure. However, the optimal post-filter iCa target should be individualized according to the patient's clinical and biological status.
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Affiliation(s)
- Mona Assefi
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France.
| | - Alix Leurent
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Florian Blanchard
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Cyril Quemeneur
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Romain Deransy
- Université de Nantes, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Antoine Monsel
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University-INSERM UMRS_959, Immunology-Immunopathology-Immunotherapy (I3), 75013 Paris, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM and Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
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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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Mariano F, Mella A, Randone P, Agostini F, Bergamo D, Berardino M, Biancone L. Safety and Metabolic Tolerance of Citrate Anticoagulation in Critically Ill Polytrauma Patients with Acute Kidney Injury Requiring an Early Continuous Kidney Replacement Therapy. Biomedicines 2023; 11:2570. [PMID: 37761011 PMCID: PMC10526994 DOI: 10.3390/biomedicines11092570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
For severe polytrauma patients with an early AKI requiring renal replacement therapy, anticoagulation remains a great challenge. Due to a high bleeding risk, hemodynamic instability, and increased lactate levels, continuous modality (CKRT) and citrate anticoagulation seem to be the most appropriate. However, their safety with regard to the potential risk of impaired citrate metabolism is not documented. A retrospective study of 60 severe polytrauma patients admitted to the emergency department between January 2000 and December 2021 was conducted; the patients requiring CKRT during the first 72 h were treated with citrate (n. 46, group Citrate) or with heparin (n. 14, group Heparin). Out of 60 patients, 31 survived (51.7%). According to logistic regression analysis, age and SOFA score were significant predictors of mortality. The incidence of rhabdomyolysis was more common in the survivors (77.4 vs. 51.7%), and Kaplan-Meyer analysis showed a better trend towards survival at 90 days for the group Citrate than the group Heparin (p 0.0956). In the group Citrate, hemorrhagic episodes were significantly less common (0.045 vs. 0.273 episodes/day, p < 0.001); the effective duration (h/day) of CKRT was longer; and the effective net ultrafiltration rate (mL/kg/h) and blood flow rate were lower. For severe polytrauma patients, early, soft CKRT with citrate anticoagulation at a low blood flow rate and circuit citratemia showed a better safety and hemodynamic stability, suggesting that citrate should be the first choice anticoagulant in this subset of patients.
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Affiliation(s)
- Filippo Mariano
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Alberto Mella
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Paolo Randone
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
| | - Fulvio Agostini
- Anesthesia and Intensive Care 3, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy; (F.A.); (M.B.)
| | - Daniela Bergamo
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
| | - Maurizio Berardino
- Anesthesia and Intensive Care 3, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy; (F.A.); (M.B.)
| | - Luigi Biancone
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (A.M.); (D.B.); (L.B.)
- Nephrology, Dialysis and Transplantation U, University Hospital City of Science and Health, CTO Hospital, 10126 Turin, Italy;
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Jacobs R, Verbrugghe W, Dams K, Roelant E, Couttenye MM, Devroey D, Jorens P. Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Life (Basel) 2023; 13:life13051198. [PMID: 37240843 DOI: 10.3390/life13051198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. METHODS Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. RESULTS Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110). CONCLUSION regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.
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Affiliation(s)
- Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Walter Verbrugghe
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Karolien Dams
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Marie Madeleine Couttenye
- Department of Nephrology and Hypertension, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
| | - Dirk Devroey
- Deparmtment of Family Medicine and Chronic Care, Faculty of Medicine and Framacy, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
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10
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Teixeira JP, Neyra JA, Tolwani A. Continuous KRT: A Contemporary Review. Clin J Am Soc Nephrol 2023; 18:256-269. [PMID: 35981873 PMCID: PMC10103212 DOI: 10.2215/cjn.04350422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AKI is a common complication of critical illness and is associated with substantial morbidity and risk of death. Continuous KRT comprises a spectrum of dialysis modalities preferably used to provide kidney support to patients with AKI who are hemodynamically unstable and critically ill. The various continuous KRT modalities are distinguished by different mechanisms of solute transport and use of dialysate and/or replacement solutions. Considerable variation exists in the application of continuous KRT due to a lack of standardization in how the treatments are prescribed, delivered, and optimized to improve patient outcomes. In this manuscript, we present an overview of the therapy, recent clinical trials, and outcome studies. We review the indications for continuous KRT and the technical aspects of the treatment, including continuous KRT modality, vascular access, dosing of continuous KRT, anticoagulation, volume management, nutrition, and continuous KRT complications. Finally, we highlight the need for close collaboration of a multidisciplinary team and development of quality assurance programs for the provision of high-quality and effective continuous KRT.
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Affiliation(s)
- J. Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Javier A. Neyra
- Division of Nephrology, Bone, and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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11
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Miyaji MJ, Ide K, Takashima K, Maeno M, Krallman KA, Lazear D, Goldstein SL. Comparison of nafamostat mesilate to citrate anticoagulation in pediatric continuous kidney replacement therapy. Pediatr Nephrol 2022; 37:2733-2742. [PMID: 35348901 DOI: 10.1007/s00467-022-05502-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is the preferred continuous kidney replacement therapy (CKRT) anticoagulation strategy for children in the USA. Nafamostat mesilate (NM), a synthetic serine protease, is used widely for CKRT anticoagulation in Japan and Korea. We compared the safety and efficacy of NM to RCA for pediatric CKRT. METHODS Starting June 2019, the most recent 100 medical records of children receiving CKRT with either RCA or NM were reviewed retrospectively, at one children's hospital in Japan (NM) and one in the USA (RCA). The number of hours a single CKRT filter was in use, was the primary outcome. Safety was assessed by bleeding complications for the NM group and citrate toxicity leading to RCA discontinuation or electrolyte imbalance in the RCA group. RESULTS Eighty patients received NM and 78 patients received RCA. Median filter life was longer for the NM group (NM: 38 [22, 74] vs. RCA: 36 [17, 66] h, p = 0.02). When filter life was censored for discontinuation other than clotting, the 60-h survival rate was higher for RCA (71% vs. 54%). The hazard ratio comparing NM over RCA varied over time (HR 0.7; 0.2-1.5, p = 0.33 at 0 h to HR 5.5; 1.3-23.7, p = 0.334 at 72 h). The lack of difference in filter survival persisted controlling for filter surface area, catheter diameter, and pre-CKRT platelet count. Major bleeding rates did not differ between groups (NM: 5% vs. RCA: 9%). CONCLUSIONS RCA and NM provide satisfactory anticoagulation for CKRT in children with no difference in major bleeding rates. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Mai J Miyaji
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
- Master of Science Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Maeno
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kelli A Krallman
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
| | - Danielle Lazear
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA.
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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12
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To HHM, Kwan AMC, Leung NYY, Chan WM, Ngai CW, Wong ASK, Tsai PNW, Ma TSK, Yam I, Ng PY, Yap DYH. A prospective study on serum citrate levels and clinical correlations in patients receiving regional citrate anticoagulation. Clin Kidney J 2022; 16:285-292. [PMID: 36755836 PMCID: PMC9900571 DOI: 10.1093/ckj/sfac223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Current ways to diagnose citrate accumulation (CA) in patients receiving regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) are confounded by various clinical factors. Serum citrate measurement emerges as a more direct way to diagnose CA, but its clinical utility and optimal cut-off values remain undefined. This study examined serum citrate kinetics and its diagnostic performance for CA in patients receiving RCA CRRT. Methods A multicentre prospective study was carried out in two tertiary referral centre intensive care units in Hong Kong with serum citrate levels measured at baseline and 2, 6, 12, 24, 36, 48 and 72 h after initiation of RCA CRRT and their relationships with the development of CA. Results Among the 133 patients analysed, 18 patients (13.5%) developed CA. The serum citrate levels at baseline and 2, 6 and 12 h after initiation of RCA CRRT in patients who had CA were significantly higher than the non-CA group (P < .001 for all). The CA group also had higher serum citrate levels than the non-CA group {median 0.93 mmol/L [interquartile range (IQR) 0.81-1.16) versus 0.37 mmol/L (IQR 0.26-0.57), P < .001}. Using a cut-off of 0.85 mmol/L, the serum citrate level had a sensitivity of 0.77 and a specificity 0.96 for the diagnosis of CA [area under the receiver operating characteristics curve (AUROC) 0.90, P < .001]. The 2-h and 6-h serum citrate levels had good discriminatory abilities for predicting subsequent development of CA (AUROC 0.86 and 0.83 for 2-h and 6-h citrate levels using cut-off values of 0.34 and 0.63 mmol/L, respectively; P < .001). Conclusion Serum citrate levels were significantly higher in patients with CA compared with patients without CA. Serum citrate levels showed good performance in diagnosing and predicting the development of CA.
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Affiliation(s)
- Harmony H M To
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Arthur M C Kwan
- Department of Anaesthesia and Intensive care, Tuen Mun Hospital, Hong Kong
| | | | - W M Chan
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - C W Ngai
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | | | - Polly N W Tsai
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Tammy S K Ma
- Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Irene Yam
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong
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13
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He J, Xiao Z, Zhou X, Cao J, Kang X, Zhang X. Comparison of different modalities of continuous renal replacement therapy with regional sodium citrate anticoagulation in paediatric patients. Int J Artif Organs 2022; 45:997-1005. [PMID: 35903018 DOI: 10.1177/03913988221115447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the efficacy and safety of continuous renal replacement therapy (CRRT) modalities with regional sodium citrate anticoagulation (RCA) in children. METHODS This retrospective study was conducted at the paediatric intensive care unit of Hunan Children's Hospital in China. Medical records of paediatric patients hospitalised for RCA-CRRT between April 2017 and March 2021 were reviewed. Patients received continuous venovenous haemodialysis, continuous venovenous haemofiltration (CVVH), or continuous venovenous haemodiafiltration (CVVHDF). RESULTS Patients on continuous venovenous haemodialysis (n = 2) were excluded because of their small sample size. The remaining participants were divided into CVVH and CVVHDF groups; 80 patients received CRRT, with 40 and 62 sessions in the CVVH and CVVHDF groups, respectively. The filtre lifespan was longer in the CVVHDF group than in the CVVH group (median value [interquartile range]; 47 [15] hours vs. 35 [17.5] hours; p = 0.029). Compared with the CVVHDF group, the hazard ratio for filtre lifespan in the CVVH group was 3.023 (95% confidence interval 1.820-5.023, p < 0.001). There were no significant differences in ionised calcium levels of the circuits between the two groups at different time points (p < 0.05). Metabolic alkalosis, hyperlactataemia, hypocalcaemia, and hypercalcaemia occurred in both groups, with metabolic alkalosis being the most common complication. No patients in either group experienced sodium citrate accumulation or hypernatraemia. Inter-group differences in the incidence of these complications were not statistically significant (p > 0.05). CONCLUSIONS Our results suggest that CVVHDF is a better option for RCA-CRRT than CVVH.
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Affiliation(s)
- Jie He
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Zhenghui Xiao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiong Zhou
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Jianshe Cao
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xiayan Kang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
| | - Xinping Zhang
- Paediatric Intensive Care Unit, Hunan Children's Hospital, Changsha, Hunan, China
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14
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Xin X, Tang J, Jia HM, Zhang TE, Zheng Y, Huang LF, Ding Q, Li JC, Guo SY, Li WX. Development of a Multivariable Prediction Model for Citrate Accumulation in Liver Transplant Patients Undergoing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2021; 51:111-121. [PMID: 33951630 DOI: 10.1159/000513947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with impaired citrate metabolism may experience citrate accumulation (CA), which causes life-threatening metabolic acidosis and hypocalcemia. CA poses a challenge for clinicians when deciding on the use of regional citrate anticoagulation (RCA) for patients with liver dysfunction. This study aimed to develop a prediction model integrating multiple clinical variables to assess the risk of CA in liver transplant patients. METHODS This single-center prospective cohort study included postoperative liver transplant patients who underwent continuous renal replacement therapy (CRRT) with RCA. The study end point was CA. A prediction model was developed using a generalized linear mixed-effect model based on the Akaike information criterion. The predictive values were assessed using the receiver operating characteristic curve and bootstrap resampling (times = 500) to estimate the area under the curve (AUC) and the corresponding 95% confidence interval (CI). A nomogram was used to visualize the model. RESULTS This study included 32 patients who underwent 133 CRRT sessions with RCA. CA occurred in 46 CRRT sessions. The model included lactate, norepinephrine >0.1 μg/kg/min, alanine aminotransferase, total bilirubin, and standard bicarbonate, which were tested before starting each CRRT session and body mass index, diabetes mellitus, and chronic kidney disease as predictors. The AUC of the model was 0.867 (95% CI 0.786-0.921), which was significantly higher than that of the single predictor (p < 0.05). A nomogram visualized the prediction model. CONCLUSIONS The prediction model integrating multiple clinical variables showed a good predictive value for CA. A nomogram visualized the model for easy application in clinical practice.
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Affiliation(s)
- Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Tang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui-Miao Jia
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tian-En Zhang
- Department of Health Science, Gettysburg College, Gettysburg, Pennsylvania, USA
| | - Yue Zheng
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li-Feng Huang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qi Ding
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jun-Cong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu-Yan Guo
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wen-Xiong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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15
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Li L, Bai M, Zhang W, Zhao L, Yu Y, Sun S. Regional citrate anticoagulation versus low molecular weight heparin for CRRT in hyperlactatemia patients: A retrospective case-control study. Int J Artif Organs 2021; 45:343-350. [PMID: 33784842 DOI: 10.1177/03913988211003586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION There were controversial opinions on the use of regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) for continuous renal replacement therapy (CRRT) in hyperlactatemia patients, which was considered as one of the contraindications of citrate. The aim of our present study is to evaluate the efficacy and safety of RCA versus LMWH for CRRT in hyperlactatemia patients. METHODS Adult patients with hyperlactatemia who underwent RCA or LMWH CRRT in our center between January 2014 and March 2018 were retrospectively recruited. Filter lifespan, ultrafiltration, purification, bleeding, citrate accumulation, filter clot, and the infusion of blood production were evaluated as endpoints. RESULTS Of the 127 patients included in the original cohort, 81 and 46 accepted RCA and LMWH CRRT, respectively. The filter lifespan was significantly prolonged in the RCA group compared to the LMWH group (44.25 h [2 -83] vs. 24 h [4 -67], p < 0.001). The accumulated filter survival proportions were significantly improved in the RCA group compared to the LMWH group in the original cohort (p < 0.001) as well as the matched group (p < 0.001). The filters clotted more frequently in the LMWH group than in the RCA group in both of the original (52.2% vs 26.8%, p = 0.001) and matched cohort (58.6% vs 19.4%, p = 0.001). The bleeding complication was significantly reduced in the RCA group than in the LMWH group in the matched cohort (28.6% vs 4.5%, p = 0.04). CONCLUSION In critically ill patients with hyperlactatemia requiring CRRT, RCA is superior to LMWH in terms of filter lifespan and bleeding risk without significantly increased risk of citrate accumulation and citrate related metabolic complications. RCA most likely is a safe and effective anticoagulation method for CRRT in patients with hyperlactatemia.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
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16
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Ronco C, Reis T. Continuous renal replacement therapy and extended indications. Semin Dial 2021; 34:550-560. [PMID: 33711166 DOI: 10.1111/sdi.12963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 01/16/2023]
Abstract
Extracorporeal blood purification (EBP) techniques provide support for critically ill patients with single or multiple organ dysfunction. Continuous renal replacement therapy (CRRT) is the modality of choice for kidney support for those patients and orchestrates the interactions between the different artificial organ support systems. Intensive care teams should be familiar with the concept of sequential extracorporeal therapy and plan on how to incorporate new treatment modalities into their daily practices. Importantly, scientific evidence should guide the decision-making process at the bedside and provide robust arguments to justify the costs of implementing new EBP treatments. In this narrative review, we explore the extended indications for CRRT as an adjunctive treatment to provide support for the heart, lung, liver, and immune system. We detail practicalities on how to run the treatments and how to tackle the most frequent complications regarding each of the therapies, whether applied alone or integrated. The physicochemical processes and technologies involved at the molecular level encompassing the interactions between the molecules, membranes, and resins are spotlighted. A clinical case will illustrate the timing for the initiation, maintenance, and discontinuation of EBP techniques.
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Affiliation(s)
- Claudio Ronco
- Department of Medicine (DIMED), University of Padova, Padova, Italy.,Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,National Academy of Medicine, Young Leadership Physicians Program, Rio de Janeiro, Brazil
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Clínica de Doenças Renais de Brasília, Molecular Pharmacology Laboratory, University of Brasília, Brasilia, Brazil
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17
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Li L, Bai M, Yu Y, Li Y, Zhao L, Sun S. Regional citrate anticoagulation vs no-anticoagulation for CRRT in hyperlactatemia patients with increased bleeding risk: A retrospective cohort study. Semin Dial 2020; 34:209-217. [PMID: 33090579 DOI: 10.1111/sdi.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/08/2020] [Accepted: 09/12/2020] [Indexed: 11/26/2022]
Abstract
There are controversial opinions on the use of regional citrate anticoagulation (RCA) continuous renal replacement therapy (CRRT) in hyperlactatemia patients with increased bleeding risk. Patients with hyperlactatemia and increased bleeding risk who accepted RCA or no-anticoagulation CRRT in our center were retrospectively included. Eighty patients who underwent RCA-CRRT and 47 patients received no-anticoagulation CRRT were included. Filter lifespan was significantly longer in the RCA group than the no-anticoagulation group (44.5 hours [2-89] vs 24.5 hours [1.5-70], P < .001). The adjusted results demonstrated that patients in the no-anticoagulant group had significantly higher risk of filter failure (HR = 4.765, 95% CI 2.703-8.4, P < .001). Bleeding episodes occurred in 19 (24.1%) and 22 (46.8%) patients in the RCA and no-anticoagulation group, respectively (P = .012). The overall citrate accumulation (CA) rate was 5% in the RCA group. Patient mortality was associated with the comorbidity of hypertension, increased serum lactate level, and increased SOFA score. After matching, the filter lifespan was significantly longer in the RCA group than the no-anticoagulation group. With careful monitoring and timely adjustment, RCA most likely was safe and effective for CRRT in hyperlactatemia patients with increased bleeding risk.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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Yang L, Wang W, Hu Y, Guo J, Huang X. Biocompatible chitosan-modified core-shell Fe 3O 4 nanocomposites for exigent removal of blood lactic acid. NANO EXPRESS 2020. [DOI: 10.1088/2632-959x/ab9b1c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Excess lactic acid in blood will lead to hyperlactatemia, which is frequently detected in critically ill patients admitted to the intensive care. Reducing the blood lactic acid content using acute treatments becomes particularly important for bringing a patient out of danger. Traditional treatments often fail in case of malfunctioning of a patients’ metabolism. Herein, nanotechnology was introduced to remove blood lactic acid independent of metabolism. In this work, chitosan was employed as the shell to adsorb lactic acid, and Fe3O4 nanoparticles were employed as the core to enable proper magnetic separation property. Our data showed that core–shell nanocomposites (NCs) had an exigent and efficient adsorption behavior. Furthermore, they could be easily separated from blood plasma by magnetic separation. Thus, the good hemocompatibility and cytocompatibility indicated that of core–shell NCs hold great potential in lactic acid removal for emergent hyperlactatemia treatment.
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Gao J, Wang F, Wang Y, Jin D, Tang L, Pan K. A mode of CVVH with regional citrate anticoagulation compared to no anticoagulation for acute kidney injury patients at high risk of bleeding. Sci Rep 2019; 9:6607. [PMID: 31036927 PMCID: PMC6488647 DOI: 10.1038/s41598-019-42916-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/10/2019] [Indexed: 12/21/2022] Open
Abstract
The study was designed to assess a practical mode of postdilution continuous venovenous hemofiltration (CVVH) with regional citrate anticoagulation (RCA) using a calcium-containing replacement solution, and to compare it with a CVVH mode with no anticoagulation (NA). Both methods were employed in our center for acute kidney injury (AKI) patients at high risk of bleeding. Fifty-six patients were equally allocated into the RCA-CVVH group and the NA-CVVH group. The study displayed no significant differences between groups involving baseline characteristics, severity level, blood gas analysis, hepatic/renal/coagulative functions, electrolytes, hemoglobin concentration, and platelet counts before or after continuous renal replacement therapy (CRRT). Compared to the NA-CVVH group, the RCA-CVVH group had a lower level of transfused packed red blood cells and platelet as well as a longer filter lifespan. The result showed no substantial differences between groups in terms of the mean supporting time and cost involving CRRT per person, the length of ICU and hospital stays, and the ICU survival. Homeostasis was basically preserved at a target range during the RCA post-CVVH procedure. Serious complications did not arise during the RCA process. RCA postdilutional CVVH is a safe and effective mode for application in AKI patients with a high risk of bleeding, and it can extend the filter lifespan and decrease blood loss, compared with the NA mode for CRRT. Further studies are needed to evaluate this mode for CRRT. (Retrospective Registration number ChiCTR1800016462, Registration date 2/6/2018)
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Affiliation(s)
- Jianping Gao
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Feng Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Yonggang Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Dan Jin
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Liping Tang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Konghan Pan
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
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20
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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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