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Yu X, Ouyang L, Li J, Peng Y, Zhong D, Yang H, Zhou Y. Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China. BMC Nurs 2024; 23:281. [PMID: 38671501 PMCID: PMC11055233 DOI: 10.1186/s12912-024-01953-6] [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: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation. METHODS This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed. RESULTS A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department. CONCLUSION ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.
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Affiliation(s)
- Xiaoyan Yu
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Lin Ouyang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Jinxiu Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Ying Peng
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Dingming Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China
| | - Huan Yang
- Blood Purification Center, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China
| | - Yanyan Zhou
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
- Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China.
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Zhu XF, Li JQ, Liu TT, Wang Y, Zhong Y, Gao QM, Zhang Q, Yu KK, Huang C, Li N, Lu Q, Zhang WH, Zhang JM, Xia R, Zheng JM. A single center retrospective study: Comparison between centrifugal separation plasma exchange with ACD-A and membrane separation plasma exchange with heparin on acute liver failure and acute on chronic liver failure. J Clin Apher 2024; 39:e22103. [PMID: 38098278 DOI: 10.1002/jca.22103] [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: 08/10/2022] [Revised: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 02/10/2024]
Abstract
The purpose of this retrospective study is to compare the efficacy and safety of the centrifugal separation therapeutic plasma exchange (TPE) using citrate anticoagulant (cTPEc) with membrane separation TPE using heparin anticoagulant (mTPEh) in liver failure patients. The patients treated by cTPEc were defined as cTPEc group and those treated by mTPEh were defined as mTPEh group, respectively. Clinical characteristics were compared between the two groups. Survival analyses of two groups and subgroups classified by the model for end-stage liver disease (MELD) score were performed by Kaplan-Meier method and were compared by the log-rank test. In this study, there were 51 patients in cTPEc group and 18 patients in mTPEh group, respectively. The overall 28-day survival rate was 76% (39/51) in cTPEc group and 61% (11/18) in mTPEh group (P > .05). The 90-day survival rate was 69% (35/51) in cTPEc group and 50% (9/18) in mTPEh group (P > .05). MELD score = 30 was the best cut-off value to predict the prognosis of patients with liver failure treated with TPE, in mTPEh group as well as cTPEc group. The median of total calcium/ionized calcium ratio (2.84, range from 2.20 to 3.71) after cTPEc was significantly higher than the ratio (1.97, range from 1.73 to 3.19) before cTPEc (P < .001). However, there was no significant difference between the mean concentrations of total calcium before cTPEc and at 48 h after cTPEc. Our study concludes that there was no statistically significant difference in survival rate and complications between cTPEc and mTPEh groups. The liver failure patients tolerated cTPEc treatment via peripheral vascular access with the prognosis similar to mTPEh. The prognosis in patients with MELD score < 30 was better than in patients with MELD score ≥ 30 in both groups. In this study, the patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) treated with cTPEc tolerated the TPE frequency of every other day without significant clinical adverse event of hypocalcemia with similar outcomes to the mTPEh treatment. For liver failure patients treated with cTPEc, close clinical observation and monitoring ionized calcium are necessary to ensure the patients' safety.
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Affiliation(s)
- Xin-Fang Zhu
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Qiang Li
- Department of Pulmonary and Critical Care Medicine, The People's Hospital of Dehong, Kunming Medical University, Yunnan, China
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Tian-Tian Liu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuan Wang
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Yao Zhong
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Qing-Mei Gao
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Qi Zhang
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Kang-Kang Yu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Chong Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Ning Li
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Qing Lu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Hong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Ji-Ming Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Rong Xia
- Department of Transfusion, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian-Ming Zheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
- National Medical Center for infectious diseases, China
- Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Fudan University, Shanghai, China
- Liver Diseases Center, Huashan Hospital, Fudan University, Shanghai, 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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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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Demuynck T, Grooteman M, Ter Wee P, Cozzolino M, Meijers B. Regional Citrate Anticoagulation: A Tale of More Than Two Stories. Semin Nephrol 2023; 43:151481. [PMID: 38212212 DOI: 10.1016/j.semnephrol.2023.151481] [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: 01/13/2024]
Abstract
Calcium is a key clotting factor, and several inorganic molecules that bind to calcium have been found to reduce the clotting propensity of blood. Citrate, a calcium chelator, is used as inhibitor of the coagulation cascade in blood transfusion. Also, it is used as an anaticoagulant during dialysis to maintain patency of the extracorporeal circuit, known as regional citrate anticoagulation (RCA). The amount of citrate should be chosen such that ionized calcium concentrations in the extracorporeal circuit are reduced enough to minimize propagation of the coagulation cascade. The dialytic removal of the calcium-citrate complexes combined with reduced ionized calcium concentrations makes necessary calcium supplementation of the blood returning to the patient. This can be achieved in different ways. In classical RCA, citrate and calcium are infused in the afferent and efferent tubing, respectively, whereas the dialysate does not contain calcium. This setup has been shown to be highly efficacious with a very low clotting propensity. Strict monitoring of blood electrolytes is required. Alternatively, the use of a high-calcium dialysate leads to calcium loading, obviating the need for a separate calcium infusion pump. The main advantages are simplified delivery of RCA and less fluctuation of systemic calcium concentrations. Currently, citric acid is sometimes added to the acid concentrate as a replacement for acetic acid. Differences and similarities between RCA and citrate-containing dialysate are discussed. RCA is an excellent alternative to heparin for patients at high risk of bleeding.
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Affiliation(s)
- Thomas Demuynck
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Muriel Grooteman
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Piet Ter Wee
- Department of Nephrology, Amsterdam UMC, Amsterdam, Netherlands; Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, University of Milan, Milan, Italy
| | - Björn Meijers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
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Nalesso F, Bettin E, Bogo M, Cacciapuoti M, Cattarin L, Scaparrotta G, Calò LA. Safety of Citrate Anticoagulation in CKRT: Monocentric Experience of a Dynamic Protocol of Calcium Monitoring. J Clin Med 2023; 12:5201. [PMID: 37629242 PMCID: PMC10455350 DOI: 10.3390/jcm12165201] [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: 07/18/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Regional Citrate Anticoagulation (RCA) is considered the first-line anticoagulation for Continuous Kidney Replacement Therapy (CKRT). The RCA requires strict protocols and trained staff to avoid unsafe use and ensure its benefit. We have analyzed all our CKRT prescriptions from December 2020 to April 2022 anonymously, collecting data on CKRT, lab tests, clinical conditions, and complications of RCA. In addition, in order to better detect citrate accumulation, we have performed an RCA protocol by reducing the CaTot/Ca2+ ratio cut-off from 2.50 to 2.40 and increasing the number of calcium checks according to its trend. Among the 374 patients in CKRT, 104 received RCA prescriptions, of which 11 (10.6%) were discontinued: 4 for the suspicion of citrate accumulation, 1 for the development of metabolic alkalosis, 1 for the shift to a different CKRT procedure due to the need for a higher bicarbonate dose, 4 for the elevation of hepatocytolysis indexes, and 1 due to a preemptive discontinuation following massive post-surgery bleeding. None of the patients have had citrate toxicity as indicated by a CaTot/Ca2+ greater than 2.50, and our protocol has allowed the early identification of patients who might develop clinical citrate toxicity.
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Affiliation(s)
- Federico Nalesso
- Department of Medicine, Nephrology, Dialysis and Transplant, University of Padua, 35128 Padua, Italy (L.A.C.)
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Senthilkumar S, Sampathkumar K, Rajiv AD, Dwarak S, Harsha HB. Clinical Trial Comparing the Efficacy and Safety of Regional Citrate Anticoagulation Versus Heparin in CRRT. Indian J Nephrol 2023; 33:254-258. [PMID: 37781556 PMCID: PMC10503585 DOI: 10.4103/ijn.ijn_169_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/30/2022] [Indexed: 10/03/2023] Open
Abstract
Introduction Heparin continues to be the most common modality of anticoagulation in CRRT. The increased risk of hemorrhagic complications associated with its use led to the emergence of regional citrate anticoagulation (RCA) as an alternative. However, the perceived complexities associated with its use and the risk of metabolic derangements have prevented it from being adopted on a larger scale. Thus, we conducted a prospective study to compare the efficacy and safety of RCA versus heparin. Methods Adult patients admitted to our ICU (November 2018-November 2019) with renal insufficiency and requiring CRRT were included in the study. It was an open-label study with 25 patients each being allotted to the heparin and citrate groups. Our primary outcome was the filter life span. Secondary outcomes included metabolic derangements, bleeding episodes, and patient survival. The starting dose of citrate was 2.0 mmol/L. Results The mean filter life span was 32.84 h in the citrate group and 30.40 h in the heparin group (p-value = 0.47). In a significant proportion of the cases, CRRT was terminated for non-filter clotting-related reasons (64% in citrate vs. 32% in heparin). Kaplan-Meir analysis was done to overcome this confounder; the filter lifespan was estimated to be 46.94 h in citrate and 40.05 h for the heparin group (p-value = 0.29). No significant metabolic derangements or bleeding episodes were noted in either group. Overall patient survival was higher in the citrate group at 52% versus 32% (p-value = 0.15) in the heparin group. Conclusion No significant difference in filter lifespan or risk of metabolic derangements was noted. A trend toward higher patient survival rates in the citrate group was noted, which warrants further evaluation in future trials.
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Affiliation(s)
- S Senthilkumar
- Department of Nephrology, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India
| | | | - Andrew Deepak Rajiv
- Department of Nephrology, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India
| | - S Dwarak
- Department of Nephrology, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India
| | - H B Harsha
- Department of Nephrology, Meenakshi Mission Hospital, Madurai, Tamil Nadu, India
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Peng B, Lu J, Guo H, Liu J, Li A. Regional citrate anticoagulation for replacement therapy in patients with liver failure: A systematic review and meta-analysis. Front Nutr 2023; 10:1031796. [PMID: 36875829 PMCID: PMC9977825 DOI: 10.3389/fnut.2023.1031796] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023] Open
Abstract
Background Citrate refers to an anticoagulant agent commonly used in extracorporeal organ support. Its application is limited in patients with liver failure (LF) due to the increased risk of citrate accumulation induced by liver metabolic dysfunction. This systematic review aims to assess the efficacy and safety of regional citrate anticoagulation in extracorporeal circulation for patients with liver failure. Methods PubMed, Web of Science, Embase, and Cochrane Library were searched. Studies regarding extracorporeal organ support therapy for LF were included to assess the efficacy and safety of regional citrate anticoagulation. Methodological quality of included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS). Meta-analysis was performed using R software (version 4.2.0). Results There were 19 eligible studies included, involving 1026 participants. Random-effect model showed an in-hospital mortality of 42.2% [95%CI (27.2, 57.9)] in LF patients receiving extracorporeal organ support. The during-treatment incidence of filter coagulation, citrate accumulation, and bleeding were 4.4% [95%CI (1.6-8.3)], 6.7% [95%CI (1.5-14.4)], and 5.0% [95%CI (1.9-9.3)], respectively. The total bilirubin(TBIL), alanine transaminase (ALT), aspartate transaminase(AST), serum creatinine(SCr), blood urea nitrogen(BUN), and lactate(LA) decreased, compared with those before the treatment, and the total calcium/ionized calcium ratio, platelet(PLT), activated partial thromboplastin time(APTT), serum potential of hydrogen(pH), buffer base(BB), and base excess(BE) increased. Conclusion Regional citrate anticoagulation might be effective and safe in LF extracorporeal organ support. Closely monitoring and timely adjusting during the process could reduce the risk for complications. More prospective clinical trials of considerable quality are needed to further support our findings. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022337767.
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Affiliation(s)
- Bo Peng
- Beijing Ditan Hospital, Capital Medical University, Beijing, China.,Beijing Fengtai Hospital, Beijing, China
| | - Jiaqi Lu
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hebing Guo
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Liu
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ang Li
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Botan E, Durak A, Gün E, Gurbanov A, Balaban B, Kahveci F, Özen H, Uçmak H, Aycan F, Kendirli T. Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation in Children with Liver Dysfunction/Failure. J Trop Pediatr 2022; 68:6614520. [PMID: 35737953 DOI: 10.1093/tropej/fmac048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Regional citrate anticoagulation (RCA) is an option but citrate accumulation is risk and it is a giving up cause for this situation. This retrospective study was conducted in the pediatric intensive care unit (PICU) between May 2019 and April 2021. We investigated 47 patients with liver failure (LF) in our PICU, and RCA during continuous renal replacement therapy (CRRT) was applied to 10 (21.3%) of them. Half of them were male (n: 5/10), their mean age was 104.7 ± 66.20 months. Nine of them needed vasoactive support during follow-up. The most common indication for CRRT was hepatorenal syndrome (40%). There was no significant difference between liver transaminases and liver function tests before and after CRRT (p > 0.05). In terms of citrate toxicity of the patients, there was no significant difference between total calcium/ionized calcium, lactate level, pH and bicarbonate values before and after CRRT (p > 0.05). The mean total CRRT time was 110.2 ± 118.2 h, and the mean circuit lifespan was 43.8 ± 48.7 h; the mean number of circuits was 2.7 ± 2.4. Total Ca/ionized Ca >2.5 was a clinically relevant endpoint, but no patient interrupted dialysis for this cause. There was no complication about RCA. This study did not observe any adverse effects on acid-base status, transaminases, an increase in bilirubin during RCA-CRRT treatment in pediatric patients with LF. Total calcium/ionized calcium ratio, serum lactate level and prothrombin time level should be closely monitored daily in terms of citrate accumulation in this patient group.
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Affiliation(s)
- Edin Botan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Ayşen Durak
- Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Emrah Gün
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Anar Gurbanov
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Burak Balaban
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Fevzi Kahveci
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Hasan Özen
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Hacer Uçmak
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Fulden Aycan
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Tanıl Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
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10
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Thanapongsatorn P, Chaijamorn W, Sirivongrangson P, Tachaboon S, Peerapornratana S, Lumlertgul N, Lucksiri A, Srisawat N. Citrate pharmacokinetics in critically ill liver failure patients receiving CRRT. Sci Rep 2022; 12:1815. [PMID: 35110648 PMCID: PMC8810887 DOI: 10.1038/s41598-022-05867-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/13/2022] [Indexed: 11/23/2022] Open
Abstract
Citrate has been proposed as anticoagulation of choice in continuous renal replacement therapy (CRRT). However, little is known about the pharmacokinetics (PK) and metabolism of citrate in liver failure patients who require CRRT with regional citrate anticoagulation (RCA). This prospective clinical PK study was conducted at King Chulalongkorn Memorial Hospital between July 2019 to April 2021, evaluating seven acute liver failure (ALF) and seven acute-on-chronic liver failure (ACLF) patients who received CRRT support utilizing RCA as an anticoagulant at a citrate dose of 3 mmol/L. For evaluation of the citrate PK, we delivered citrate for 120 min and then stopped for a further 120 min. Total body clearance of citrate was 152.5 ± 50.9 and 195.6 ± 174.3 mL/min in ALF and ACLF, respectively. The ionized calcium, ionized magnesium, and pH slightly decreased after starting citrate infusion and gradually increased to baseline after stopping citrate infusion. Two of the ACLF patients displayed citrate toxicity during citrate infusion, while, no ALF patient had citrate toxicity. In summary, citrate clearance was significantly decreased in critically ill ALF and ACLF patients receiving CRRT. Citrate use as an anticoagulation in these patients is of concern for the risk of citrate toxicity.
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Affiliation(s)
- Peerapat Thanapongsatorn
- Central Chest Institute of Thailand, Nonthaburi, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | | | - Phatadon Sirivongrangson
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Department of Medicine, Somdech Phra Pinklao Hospital, Bangkok, Thailand
| | - Sasipha Tachaboon
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Sadudee Peerapornratana
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Nuttha Lumlertgul
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Aroonrut Lucksiri
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Nattachai Srisawat
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Division of Nephrology, Department of Medicine, Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand. .,Academy of Science, Royal Society of Thailand, Bangkok, Thailand. .,Center of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, 10330, Thailand.
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11
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Shaikhouni S, Yessayan L. Management of Acute Kidney Injury/Renal Replacement Therapy in the Intensive Care Unit. Surg Clin North Am 2021; 102:181-198. [PMID: 34800386 DOI: 10.1016/j.suc.2021.09.013] [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: 10/19/2022]
Abstract
Common causes of acute kidney injury (AKI) in the ICU setting include acute tubular necrosis (due to shock, hemolysis, rhabdomyolysis, or procedures that compromise renal perfusion), abdominal compartment syndrome, urinary retention, and interstitial nephritis. Treatment is geared toward addressing the underlying cause. Dialysis may be required if renal injury does not resolve. Early initiation of dialysis based on the stage of AKI alone has not been shown to provide a mortality benefit. Dialysis modalities are based on the dialysis indication and the patient's clinical status. Providers should pay close attention to nutritional requirements and medication dosing according to renal function and dialysis modality.
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Affiliation(s)
- Salma Shaikhouni
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
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12
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Warnar C, Faber E, Katinakis PA, Schermer T, Spronk PE. Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy. J Clin Monit Comput 2021; 36:871-877. [PMID: 33991270 DOI: 10.1007/s10877-021-00719-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.
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Affiliation(s)
- C Warnar
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - E Faber
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - P A Katinakis
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - T Schermer
- Department of Epidemiology, Gelre Hospitals, Apeldoorn , The Netherlands
| | - P E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.,Expertise Center for Intensive Care Rehabilitation Apeldoorn - ExpIRA, Gelre Hospitals, Apeldoorn , The Netherlands
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13
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Metformin-Induced Lactic Acidosis: A Question of Time. Case Rep Crit Care 2020; 2020:6962591. [PMID: 33145113 PMCID: PMC7596499 DOI: 10.1155/2020/6962591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 08/01/2020] [Accepted: 10/14/2020] [Indexed: 12/03/2022] Open
Abstract
Metformin is an oral antidiabetic largely prescribed in the treatment of type II diabetes. Overdose is associated with life-threatening lactic acidosis. We report the case of the highest metformin concentration ever described secondary to a voluntary suicidal intake. The patient developed a severe lactic acidosis and hemodynamic shock successfully treated with high-flow hemofiltration. Time to start extrarenal epuration is capital to avoid poor evolution.
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14
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Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
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15
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A novel predictive score for citrate accumulation among patients receiving artificial liver support system therapy with regional citrate anticoagulation. Sci Rep 2020; 10:12861. [PMID: 32732928 PMCID: PMC7393513 DOI: 10.1038/s41598-020-69902-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/15/2020] [Indexed: 02/05/2023] Open
Abstract
Patients with liver failure may suffer citrate accumulation when using regional citrate anticoagulation for artificial liver support system therapy (RCA-ALSS therapy). This study aimed to develop a predictive scoring system to stratify the risk of citrate accumulation. A total of 338 patients treated with RCA-ALSS therapy were retrospectively enrolled and randomly divided into derivation and validation cohorts. Longer duration of citrate accumulation (LDCA) was defined as the presence of citrate accumulation 2 h after RCA-ALSS therapy. Four baseline variables were found to be independently associated with LDCA: gender, international normalized ratio of prothrombin time, serum creatinine, and serum chloride. A predictive R-CA model and its simplified R-CA score were developed. The R-CA model (AUROC = 0.848) was found to be superior to the MELD score (AUROC = 0.725; p = 0.022) and other univariate predictors (AUROCs < 0.700; all p ≤ 0.001) in predicting LDCA. The R-CA score (AUROC = 0.803) was as capable as the R-CA model (p = 0.369) and the MELD score (p = 0.174), and was superior to other univariate predictors (all p < 0.05) in predicting LDCA. An R-CA score of 0–2 had a negative predictive value of 90.2% for LDCA. Our R-CA score reliably predicts LDCA in patients with RCA-ALSS therapy, and it is easy to use. Patients with R-CA score of 0–2 can safely receive RCA-ALSS therapy, while others should be carefully evaluated before treatment. Trial registration: Chinese Clinical Trial Registry, ChiCTR2000029179. Registered 17 January 2020, https://www.chictr.org.cn/showproj.aspx?proj=48084.
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16
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Renal replacement therapy: a practical update. Can J Anaesth 2019; 66:593-604. [PMID: 30725343 DOI: 10.1007/s12630-019-01306-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is defined as an abrupt decrease in kidney function, with the most severe form requiring some method of renal replacement therapy (RRT). The use of RRT is required in 5-10% of critically ill patients who develop severe AKI. Renal replacement therapy can be provided as either intermittent hemodialysis or one of the various modes of continuous renal replacement therapy (CRRT), with CRRT potentially conferring an advantage with respect to renal recovery and dialysis independence. There is no difference in mortality when comparing low (< 25 mL·kg-1·hr-1) vs high (> 40 mL·kg-1·hr-1) RRT dosing. Continuous renal replacement therapy may be run in different modes of increasing complexity depending on a given patient's clinical needs. Regional citrate anticoagulation is recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.
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17
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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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18
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Matoušek V, Herold I, Holanová L, Balík M. A Rare Case of Severe Metabolic Alkalosis with Unusual Hyperproteinemia Treated with Continuous Renal Replacement Therapy and Regional Citrate Anticoagulation. Case Rep Nephrol Dial 2018; 8:138-146. [PMID: 30197902 PMCID: PMC6120368 DOI: 10.1159/000491628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/28/2018] [Indexed: 12/05/2022] Open
Abstract
A 23-year-old woman was referred to the tertiary centre with acute kidney injury and severe metabolic alkalosis following an accidental ethylene glycol poisoning. The patient had been treated with continuous haemodiafiltration and regional citrate anticoagulation, and a tracheostomy was performed due to pneumonia. Besides severe metabolic alkalosis and hypernatremia, the laboratory tests revealed total protein of 108 g/L on admission to the tertiary centre. The haemodiafiltration with regional citrate anticoagulation continued with parallel correction of the alkalosis and normalisation of the total plasma protein. The tracheostomy was decannulated and the patient was discharged to the district hospital. The case demonstrates the usefulness of regional citrate anticoagulation even in severe metabolic alkalosis which was likely related to the method setting prior to admission and to an overcompensation of the initial severe metabolic acidosis. The unusual hyperproteinaemia might be interpreted with the aid of the Stewart-Fencl model of the acid-base regulation.
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Affiliation(s)
- Vojtěch Matoušek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ivan Herold
- Department of Anaesthesiology and Intensive Care, Regional Hospital Mladá Boleslav, Mladá Boleslav, Czech Republic
| | - Lenka Holanová
- Department of Anaesthesiology and Intensive Care, Regional Hospital Mladá Boleslav, Mladá Boleslav, Czech Republic
| | - Martin Balík
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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19
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Grützner TM, Listunova L, Fabian GA, Kramer BA, Flach D, Weisbrod M, Roesch-Ely D, Sharma A. Serum calcium levels and neuropsychological performance in depression and matched healthy controls: Reversal of correlation a marker of the aging cognitive clock? Psychoneuroendocrinology 2018; 91:198-205. [PMID: 29587243 DOI: 10.1016/j.psyneuen.2018.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/18/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is associated with cognitive impairment, that might be related to disturbed calcium homeostasis. Calcium-related processes have also been implicated in age related cognitive decline. Since serum calcium and brain interstitial fluids maintain long-term equilibrium under normal physiological states, serum calcium levels could affect neuronal and hence cognitive function. High serum calcium has been associated with cognitive decline in geriatric populations, whereas evidence for MDD and healthy populations is less consistent. METHODS Differences in neuropsychological (NPS) performance and their relationship with serum calcium (total, ionized, total to ionized ratio) in (partially) remitted MDD patients (n = 59) and healthy controls (HC) (n = 59) individually matched for age, gender and education (age-range 19-60 years) were examined. Modulation of study parameters and their interaction by the factor age was investigated, with subgroups young and old divided at median = 37 years. Participants provided blood samples and completed an extensive NPS test battery. RESULTS MDD showed significantly poorer NPS performance compared to HC. Serum calcium associated positively with NPS performance in HC and negatively in MDD for entire age-range samples. While younger MDD and HC showed positive NPS-calcium correlations, older MDD and HC exhibited negative NPS-calcium correlations ('correlation reversal'). Age had a significant effect on cognition and ionized calcium and interacted with illness-status, with an exaggerated influence on cognition in MDD compared to HC. CONCLUSIONS The results place calcium 'correlation reversal' to early middle-age time window, which may be accelerated for MDD and highlight the central role of calcium pathways in normal and pathological cognitive aging.
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Affiliation(s)
- Thea Marianne Grützner
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany.
| | - Lena Listunova
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany
| | - Gregor Amadeus Fabian
- MVZ Laboratory PD Dr. Volkmann and Colleagues, Kriegsstraße 99, 76133, Karlsruhe, Germany
| | - Benedikt Alexander Kramer
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany
| | - Daniel Flach
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany
| | - Matthias Weisbrod
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany; Department of Psychiatry and Psychotherapy, SRH Hospital Karlsbad-Langensteinbach, Guttmannstraße 1, 76307, Karlsbad, Germany
| | - Daniela Roesch-Ely
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany
| | - Anuradha Sharma
- Research Group Neurocognition, Department of General Psychiatry, Center for Psychosocial Medicine, University of Heidelberg, Voßstraße 4, 69115, Heidelberg, Germany
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20
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Kwon HM, Jun IG, Lee J, Moon YJ, Jung KW, Jeong HW, Park YS, Song JG, Hwang GS. Prevalent metabolic derangement and severe thrombocytopenia in ABO-incompatible liver recipients with pre-transplant plasma exchange. Sci Rep 2018; 8:6679. [PMID: 29703920 PMCID: PMC5923210 DOI: 10.1038/s41598-018-24887-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/11/2018] [Indexed: 12/12/2022] Open
Abstract
Desensitisation with therapeutic plasma exchange (TPE) is essential for ABO-incompatible (ABO-I) liver transplants (LTs). However, excessive citrate load and coagulation disturbances after TPE have been poorly studied, in particular in cirrhotic patients with hypocapnic alkalosis, metabolic compensation and electrolyte imbalances. We retrospectively evaluated 1123 consecutive LT recipients (923 ABO-compatible [ABO-C], 200 ABO-I) from November 2008 to May 2015. TPE was generally performed a day before LT and blood sampling was performed before anaesthesia induction. We performed propensity score matching (PSM) and inverse probability treatment weighting (IPTW) analyses. In 199 PSM pairs, metabolic alkalosis was prevalent in ABO-I LT recipients (expectedly due to citrate conversion) with higher pH ≥ 7.50 (IPTW-adjusted odds ratio [aOR] = 2.23) than in ABO-C LT recipients. With increasing cirrhosis severity, the arterial pH and bicarbonate levels showed dose-dependent relationships, whereas mild hypoxaemia was more prevalent in ABO-I LT recipients. ABO-I LT recipients exhibited worsened hypokalaemia ≤3.0 mmol/l (17.6%, aOR = 1.44), hypomagnesaemia ≤1.7 mg/dl (27.6%, aOR = 3.43) and thrombocytopenia <30,000/µl (19.1%, aOR = 2.26) confirmed by lower maximal clot firmness (P = 0.001) in rotational thromboelastometry (EXTEM), which necessitated platelet transfusions. Preoperative identification of these change may prevent worsening of severe electrolyte disturbances and thrombocytopenia for optimal LT anaesthesia.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - JungBok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine Seoul, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye-Won Jeong
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Ma Y, Xu Y, Chen F, Wang Y, Bai L, Tang H. Good Tolerance of Citrate Accumulation due to Plasma Exchange among Patients with Acute-on-Chronic Liver Failure: A Prospective, Observational Study. Can J Gastroenterol Hepatol 2018; 2018:4909742. [PMID: 29850456 PMCID: PMC5932514 DOI: 10.1155/2018/4909742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/07/2018] [Accepted: 02/26/2018] [Indexed: 02/05/2023] Open
Abstract
Aim To assess the tolerance of citrate accumulation due to plasma exchange (PE) among patients with acute-on-chronic liver failure (ACLF). Methods A prospective, observational study was conducted among patients with ACLF who received heparin anticoagulation during PE-centered therapy without filtration and dialysis. Citrate accumulation was defined as the value of total calcium (Catot) to ionized calcium (Caion) ratio (Catot/Caion) greater than or equal to 2.5 (Catot/Caion ≥ 2.5). Results Fifty-four patients were enrolled. The mean age and MELD score were 50.0 ± 11.3 years old and 25 ± 7, respectively. Thirty-three patients had liver cirrhosis. The total 3-month survival rate was 57.4% (31/54). The mean Catot/Caion at the time before PE was 2.05 ± 0.14. Catot/Caion ≥ 2.5 occurred in 100.0% (54/54) and 29.6% (16/54) of patients with mean Catot/Caion of 4.34 ± 1.52 and 2.36 ± 0.32 immediately after PE and 1 hour after PE, respectively, and these levels were much higher than those before PE (p < 0.01). However, all values returned to lower than 2.5 by the next morning with no difference from those before PE (2.10 ± 0.14 versus 2.05 ± 0.14, p > 0.05). Hypocalcemia (ionized calcium) and mild alkalosis were the main metabolic alterations. No symptoms associated with hypocalcemia occurred. Conclusions Citrate accumulation is well tolerated by patients with ACLF who receive PE-centered therapy without filtration and dialysis. This study is regeristed with ChiCTR-OOC-17013618.
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Affiliation(s)
- Yuanji Ma
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Yan Xu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Fang Chen
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Ying Wang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, China
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Hill S, Creighton E, Walter E. The safety of regional citrate anticoagulation in renal replacement therapy. J Intensive Care Soc 2018; 19:86. [PMID: 29456612 DOI: 10.1177/1751143717735749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Simon Hill
- Royal Surrey County Hospital, Guildford, UK
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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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Thompson A, Li F, Gross AK. Considerations for Medication Management and Anticoagulation During Continuous Renal Replacement Therapy. AACN Adv Crit Care 2017; 28:51-63. [PMID: 28254856 DOI: 10.4037/aacnacc2017386] [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] [Indexed: 11/01/2022]
Abstract
Providing safe and high-quality care to critically ill patients receiving continuous renal replacement therapy (CRRT) includes adequate drug dosing and evaluation of patients' response to medications during therapy. Pharmacokinetic drug studies in acute kidney injury and CRRT are limited, considering the number of medications used in critical care. Therefore, it is important to understand the basic principles of drug clearance during CRRT by evaluating drug properties, CRRT modalities, and how they affect medication clearance. Few published studies have addressed drug disposition and clinical response during CRRT. Additionally, clotting in the CRRT circuit is a concern, so a few options for anticoagulation strategies are presented. This article reviews (1) the CRRT system and drug property factors that affect medication management, (2) the evidence available to guide drug dosing, and (3) anticoagulation strategies for critically ill patients receiving CRRT.
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Affiliation(s)
- Ashley Thompson
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
| | - Fanny Li
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
| | - A Kendall Gross
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
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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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26
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Rico MP, Fernández Sarmiento J, Rojas Velasquez AM, González Chaparro LS, Gastelbondo Amaya R, Mulett Hoyos H, Tibaduiza D, Quintero Gómez AM. Regional citrate anticoagulation for continuous renal replacement therapy in children. Pediatr Nephrol 2017; 32:703-711. [PMID: 27896442 DOI: 10.1007/s00467-016-3544-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulation of the continuous renal replacement therapy (CRRT) circuit is an important technical aspect of this medical procedure. Most studies evaluating the efficacy and safety of citrate use have been carried out in adults, and little evidence is available for the pediatric patient population. The aim of this study was to compare regional citrate anticoagulation versus systemic heparin anticoagulation in terms of the lifetime of hemofilters in a pediatric population receiving CRRT at a pediatric center in Bogota, Colombia. METHODS This was an analytical, observational, retrospective cohort study in which we assessed the survival of 150 hemofilters (citrate group 80 hemofilters, heparin group 70 hemofilters) used in a total of 3442 hours of CCRT (citrate group 2248 h, heparin group 1194 h). Hemofilter survival was estimated beginning at placement and continuing until filter replacement due to clotting or high trans-membrane pressures. RESULTS Hemofilter survival was higher in the citrate group than in the heparin group (72 vs. 18 h; p <0.0001). Bivariate analysis showed that the hemofilter coagulation risk was significantly increased when heparin was used, regardless of hemofilter size and pump flow (hazard ratio 3.70, standard error 0.82, 95% confidence interval 2.39-5.72; p <0.00001). CONCLUSIONS Regional citrate anticoagulation could be more effective than heparin systemic anticoagulation in terms of prolonging the hemofilter lifetime in patients with acute renal injury who require CRRT.
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Affiliation(s)
- Mayerly Prada Rico
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Jaime Fernández Sarmiento
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia.
| | - Ana María Rojas Velasquez
- Division of Pediatric Gastroenterology, Pediatric Gastroenterology, Hepatology and Nutrition Unit, GASTRONUTRIPED, Bogota, Cundinamarca, Colombia
| | - Luz Stella González Chaparro
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Ricardo Gastelbondo Amaya
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Hernando Mulett Hoyos
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia
| | - Daniel Tibaduiza
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia
| | - Ana Maria Quintero Gómez
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
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27
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CRRT Regional Anticoagulation Using Citrate in the Liver Failure and Liver Transplant Population. Crit Care Nurs Q 2016; 39:241-51. [DOI: 10.1097/cnq.0000000000000118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Antonic M, Gubensek J, Buturovic-Ponikvar J, Ponikvar R. Treatment Efficacy and Safety During Plasma Exchange With Citrate Anticoagulation: A Randomized Study of 4 Versus 15% Citrate. Artif Organs 2015; 40:368-75. [DOI: 10.1111/aor.12559] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Manja Antonic
- General Hospital Celje; Celje Slovenia
- University Medical Center Ljubljana
| | - Jakob Gubensek
- University Medical Center Ljubljana
- Faculty of Medicine; University of Ljubljana; Ljubljana Slovenia
| | | | - Rafael Ponikvar
- University Medical Center Ljubljana
- Faculty of Medicine; University of Ljubljana; Ljubljana Slovenia
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29
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Ashbrook MJ, McDonough KL, Pituch JJ, Christopherson PL, Cornell TT, Selewski DT, Shanley TP, Blatt NB. Citrate modulates lipopolysaccharide-induced monocyte inflammatory responses. Clin Exp Immunol 2015; 180:520-30. [PMID: 25619261 DOI: 10.1111/cei.12591] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 12/25/2022] Open
Abstract
Citrate, a central component of cellular metabolism, is a widely used anti-coagulant due to its ability to chelate calcium. Adenosine triphosphate (ATP)-citrate lyase, which metabolizes citrate, has been shown to be essential for inflammation, but the ability of exogenous citrate to impact inflammatory signalling cascades remains largely unknown. We hypothesized that citrate would modulate inflammatory responses as both a cellular metabolite and calcium chelator, and tested this hypothesis by determining how clinically relevant levels of citrate modulate monocyte proinflammatory responses to lipopolysaccharide (LPS) in a human acute monocytic leukaemia cell line (THP-1). In normal medium (0.4 mM calcium), citrate inhibited LPS-induced tumour necrosis factor (TNF)-α and interleukin (IL)-8 transcripts, whereas in medium supplemented with calcium (1.4 mM), TNF-α and IL-8 levels increased and appeared independent of calcium chelation. Using an IL-8-luciferase plasmid construct, the same increased response was observed in the activation of the IL-8 promoter region, suggesting transcriptional regulation. Tricarballylic acid, an inhibitor of ATP-citrate lyase, blocked the ability of citrate to augment TNF-α, linking citrate's augmentation effect with its metabolism by ATP-citrate lyase. In the presence of citrate, increased histone acetylation was observed in the TNF-α and IL-8 promoter regions of THP-1 cells. We observed that citrate can both augment and inhibit proinflammatory cytokine production via modulation of inflammatory gene transactivation. These findings suggest that citrate anti-coagulation may alter immune function through complex interactions with the inflammatory response.
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Affiliation(s)
- M J Ashbrook
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - K L McDonough
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - J J Pituch
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - P L Christopherson
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T T Cornell
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - D T Selewski
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - T P Shanley
- Pediatric Critical Care, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - N B Blatt
- Divisions of Pediatric Nephrology, University of Michigan, Ann Arbor, MI, USA
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30
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Ducq P, Delaporte E. Anticoagulation régionale des circuits extracorporels par le citrate. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0927-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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31
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Sponholz C, Settmacher U, Bauer M, Kortgen A. Regional citrate anticoagulation for continuous renal replacement therapy in the perioperative care of liver transplant recipients: a single center experience. Ther Apher Dial 2014; 19:8-15. [PMID: 25196675 DOI: 10.1111/1744-9987.12196] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Kidney injury with concomitant hemodialysis is a common finding in perioperative care of liver transplant patients. The aim of this study was to evaluate disturbances in acid-base status, electrolyte balance and citrate accumulation during hemodialysis with regional citrate anticoagulation in perioperative care of liver transplant recipients. A retrospective, single center evaluation was conducted of patients with severe liver dysfunction receiving renal replacement therapy in the perioperative care of liver transplantation in a multidisciplinary ICU of a university hospital. Within 5 days of ICU stay, 89 patients undergoing liver transplantation received regional citrate anticoagulation for hemodialysis. During the study period pH (7.39 [7.33/7.43] vs. 7.44 [7.39/7.47], P-value = 0.014), base excess values (-0.9 [-5.08/2.35] vs. 4.3 [1.93/8.21], P-value = 0.001) and standard bicarbonate (23.6 [20/26.9] vs. 28.2 [26.2/32.2], P-value = 0.001) significantly increased, whereas lactate levels (2.6 [1.60/4.45] vs. 1.25 [0.98/1.9], P-value = 0.071) and Catot /Caion -ratio decreased or remained below the upper reference. Hypocalcemia appeared mostly within 48 h after dialysis initiation. Although sodium levels increased during the observation, rates of hypernatremia were comparable between hemodialysis days 1 and 5. Hemodialysis using regional citrate anticoagulation remains a challenge in the perioperative care of liver transplant recipients. Major attention must be paid to acid-base disturbances and citrate accumulation within 48 h after dialysis initiation. Nevertheless, regional citrate anticoagulation in liver dysfunction is a feasible and valuable tool, when limitations and pitfalls are adequately considered.
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Affiliation(s)
- Christoph Sponholz
- Department of Anaesthesiology and Critical Care Medicine, Visceral and Vascular Surgery, Jena, Germany
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Morabito S, Pistolesi V, Tritapepe L, Fiaccadori E. Regional citrate anticoagulation for RRTs in critically ill patients with AKI. Clin J Am Soc Nephrol 2014; 9:2173-88. [PMID: 24993448 DOI: 10.2215/cjn.01280214] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.
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Affiliation(s)
- Santo Morabito
- Department of Nephrology and Urology, Hemodialysis Unit and
| | | | - Luigi Tritapepe
- Department of Anesthesiology and Intensive Care, Sapienza University, Rome, Italy; and
| | - Enrico Fiaccadori
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University, Parma, Italy
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Abstract
OBJECTIVE To provide the pediatric intensivist an in-depth understanding of citrate as regional anticoagulant during continuous renal replacement therapy. DATA SOURCES AND DATA SELECTION We searched the PubMed.gov database using the initial key words: citrate anticoagulation [title] AND continuous; citrate [title] AND pediatric AND continuous; prospective pediatric renal replacement AND citrate; and regional citrate anticoagulation. Additional searchers were performed using EMBASE, CINAHL, and SCOPUS with similar keywords and limits. Further articles were gathered from bibliographic references of relevant studies and reviews. Only articles published in English were reviewed. DATA EXTRACTION AND DATA SYNTHESIS In the pediatric population, there are no prospective interventional or randomized studies comparing regional versus systemic anticoagulation. However, there are 11 (retrospective and prospective observational studies) in the pediatric population using citrate anticoagulation. These studies have shown that regional citrate anticoagulation in the pediatric population can be effective, provide equivalent circuit survival, and decrease bleeding compared with heparin anticoagulation. In the adult population, there are six prospective randomized controlled trials comparing the efficacy of regional citrate anticoagulation versus heparin. Two systematic reviews with meta-analysis of these six trials have been performed. The adult data on the use of regional citrate anticoagulation during continuous renal replacement therapy show a decreased risk of bleeding and at the least equivalent circuit survival as compared to heparin. Current pediatric and adult studies support regional citrate anticoagulation as an effective alternative to systemic heparin anticoagulation in most patient populations. CONCLUSIONS Continuous renal replacement therapy is the most common modality of renal replacement in the critical care setting. Regional anticoagulation is an ideal option in a critically ill child after recent surgery or with coagulopathy. Therefore, regional citrate anticoagulation in the pediatric critical care population requiring renal replacement therapy is commonly employed. Complications of citrate anticoagulation can be avoided with a greater understanding of the properties and clearance of citrate. Continued reporting of observational data and the development of prospective multicenter trials using citrate anticoagulation are needed to ensure safe and standardized care in the pediatric population.
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Continuous renal replacement therapy with regional citrate anticoagulation: do we really know the details? Curr Opin Anaesthesiol 2014; 26:428-37. [PMID: 23673990 DOI: 10.1097/aco.0b013e3283620224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW A significant proportion of critically ill patients with acute kidney injury require continuous renal replacement therapy (CRRT). This article summarizes current evidence on the diagnosis and treatment of acute kidney injury. Regional citrate anticoagulation (RCA) is an emerging but complex technique. A variety of solutions and systems are currently used for RCA. Descriptions of the dosage and methods differ significantly and may cause confusion in everyday practice. This article reviews important scientific findings and highlights pharmacological and pathophysiological aspects of RCA, with a special emphasis on practical clinical issues regarding dosage and available citrate solutions. RECENT FINDINGS RCA provides a similar or even longer circuit run, with manageable metabolic complications. Although large-scale multicentre trials are needed, there is increasing evidence for the benefits of citrate solutions in CRRT. International guidelines recommend using citrate anticoagulation rather than heparin in patients without contraindications against citrate. SUMMARY RCA-CRRT is a technique that can be safely used in the majority of intensive care patients with severe multiple-organ failure. The range of citrate solutions available, the different methods in use--continuous venovenous haemofiltration, continuous venovenous haemodialysis and continuous venovenous haemodiafiltration--and the lack of a generally accepted complete CRRT 'set' have impeded implementation of the technique in clinical practice. Unresolved questions regarding dosage and assessment preclude evidence-based comparison in prospective, multicentre studies. For the moment, each institution has to develop a local working protocol. In clinical practice, detailed staff training and monitoring of possible metabolic disturbances for this complex intervention is essential.
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Ricci Z, Ronco C. Year in review 2012: Critical Care--Nephrology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:246. [PMID: 24267346 PMCID: PMC4056329 DOI: 10.1186/cc13126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We summarize original research in the field of critical care nephrology accepted or published in 2012 in Critical Care and, when considered relevant or directly linked to this research, in other journals. Three main topics have been identified for a rapid overview: acute kidney injury, detailed in some pathogenetic and epidemiological aspects; fluid overload as a predictor of mortality both in acute kidney injury and renal replacement therapy (RRT) patients; and RRT, evaluating some features of citrate anticoagulation and describing the effects of RRT modalities or timing on survival.
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Khadzhynov D, Schelter C, Lieker I, Mika A, Staeck O, Neumayer HH, Peters H, Slowinski T. Incidence and outcome of metabolic disarrangements consistent with citrate accumulation in critically ill patients undergoing continuous venovenous hemodialysis with regional citrate anticoagulation. J Crit Care 2013; 29:265-71. [PMID: 24360392 DOI: 10.1016/j.jcrc.2013.10.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/09/2013] [Accepted: 10/20/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Systemic citrate accumulation is a complication of regional citrate anticoagulation (RCA) during continuous renal replacement therapy (CRRT). Our objective was to determine the incidence of clinical signs consistent with citrate accumulation in a large and representative cohort of intensive care unit patients undergoing RCA-CRRT. METHODS Patients treated with RCA-CRRT during 2008-2010 were retrospectively analyzed. Decreased systemic ionized calcium (iCa), increased demand for calcium substitution, elevated total calcium to iCa ratio, and metabolic acidosis were evaluated as indicators for citrate accumulation. RESULTS In the 3-year period, 1070 patients were treated with RCA-continuous venovenous hemodialysis. Metabolic signs of citrate accumulation occurred in 32 patients (2.99%, 64.5 ± 14.0 years, 65.6% male, Acute Physiology and Chronic Health Evaluation score 34.2 ± 9.7): systemic iCa decreased to 1.01 ± 0.10 mmol/L with a simultaneous increase of the calcium substitution rate to 129% ± 26%, and the mean total calcium to iCa ratio increased to 2.51 ± 0.54. All 32 patients had therapy-resistant shock with severe lactic acidosis (pH 7.20 ± 0.11, lactate 136 ± 61 mg/dL), indicating severe intracellular hypoxia. None of the patients survived. CONCLUSIONS The incidence of disarrangements consistent with citrate accumulation in patients undergoing RCA-continuous venovenous hemodialysis was low, taking place exclusively in patients with severe lactic acidosis due to multiorgan failure. This suggests that the appearance of citrate accumulation is secondary to a severe failure of cellular respiration.
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Affiliation(s)
- Dmytro Khadzhynov
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Christin Schelter
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Ina Lieker
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Alice Mika
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Hans-H Neumayer
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Harm Peters
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
| | - Torsten Slowinski
- Department of Nephrology, Charité Universitätsmedizin Berlin, Charité Campus Mitte, Humboldt University Berlin, D-10117 Berlin, Germany.
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Morabito S, Pistolesi V, Tritapepe L, Vitaliano E, Zeppilli L, Polistena F, Fiaccadori E, Pierucci A. Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid-base status and phosphate supplementation needs. BMC Nephrol 2013; 14:232. [PMID: 24156306 PMCID: PMC4015288 DOI: 10.1186/1471-2369-14-232] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 10/22/2013] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Recent guidelines suggest the adoption of regional citrate anticoagulation (RCA) as first choice CRRT anticoagulation modality in patients without contraindications for citrate. Regardless of the anticoagulation protocol, hypophosphatemia represents a potential drawback of CRRT which could be prevented by the adoption of phosphate-containing CRRT solutions. The aim was to evaluate the effects on acid-base status and phosphate supplementation needs of a new RCA protocol for Continuous Venovenous Hemodiafiltration (CVVHDF) combining the use of citrate with a phosphate-containing CRRT solution. METHODS To refine our routine RCA-CVVH protocol (12 mmol/l citrate, HCO3- 32 mmol/l replacement fluid) (protocol A) and to prevent CRRT-related hypophosphatemia, we introduced a new RCA-CVVHDF protocol (protocol B) combining an 18 mmol/l citrate solution with a phosphate-containing dialysate/replacement fluid (HCO3- 30 mmol/l, Phosphate 1.2). A low citrate dose (2.5-3 mmol/l) and a higher than usual target circuit-Ca(2+) (≤ 0.5 mmol/l) have been adopted. RESULTS Two historical groups of heart surgery patients (n = 40) underwent RCA-CRRT with protocol A (n = 20, 102 circuits, total running time 5283 hours) or protocol B (n = 20, 138 circuits, total running time 7308 hours). Despite higher circuit-Ca(2+) in protocol B (0.37 vs 0.42 mmol/l, p < 0.001), circuit life was comparable (51.8 ± 36.5 vs 53 ± 32.6 hours). Protocol A required additional bicarbonate supplementation (6 ± 6.4 mmol/h) in 90% of patients while protocol B ensured appropriate acid-base balance without additional interventions: pH 7.43 (7.40-7.46), Bicarbonate 25.3 (23.8-26.6) mmol/l, BE 0.9 (-0.8 to +2.4); median (IQR). No episodes of clinically relevant metabolic alkalosis, requiring modifications of RCA-CRRT settings, were observed. Phosphate supplementation was needed in all group A patients (3.4 ± 2.4 g/day) and in only 30% of group B patients (0.5 ± 1.5 g/day). Hypophosphatemia developed in 75% and 30% of group A and group B patients, respectively. Serum phosphate was significantly higher in protocol B patients (P < 0.001) and, differently to protocol A, appeared to be steadily maintained in near normal range (0.97-1.45 mmol/l, IQR). CONCLUSIONS The proposed RCA-CVVHDF protocol ensured appropriate acid-base balance without additional interventions, providing prolonged filter life despite adoption of a higher target circuit-Ca(2+). The introduction of a phosphate-containing solution, in the setting of RCA, significantly reduced CRRT-related phosphate depletion.
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Affiliation(s)
- Santo Morabito
- Department of Nephrology and Urology, Hemodialysis Unit, Umberto I, Policlinico di Roma, "Sapienza" University, Rome, Italy.
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Nurmohamed SA, Jallah BP, Vervloet MG, Yldirim G, ter Wee PM, Groeneveld ABJ. Continuous venovenous haemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency: a prospective observational study. BMC Nephrol 2013; 14:89. [PMID: 23597045 PMCID: PMC3637474 DOI: 10.1186/1471-2369-14-89] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 04/09/2013] [Indexed: 11/10/2022] Open
Abstract
Background There is ongoing controversy concerning optimum anticoagulation and buffering in continuous venovenous haemofiltration (CVVH). Regional anticoagulation with trisodium citrate also acting as a buffer in the replacement fluid has several advantages and disadvantages over prefilter citrate administration alone. We analysed a large cohort of patients with acute kidney injury (AKI) treated by the former method and hypothesized that it is safe and efficacious. Methods Patients admitted at the intensive care unit with AKI and a high bleeding risk, without exclusion of liver disease, treated by CVVH with citrate in a custom-made replacement solution were prospectively included. Patient and CVVH characteristics, including citrate accumulation, were evaluated in outcome groups. A standardized mortality rate (SMR) was calculated using the simplified acute physiology score II. Results Ninety-seven patients were included; metabolic control was adequate and did not differ between outcome groups, apart from lower pH/bicarbonate in non-survivors. Citrate accumulation was proven in 9% and was timely identified. These patients had about threefold higher plasma transaminases and higher CVVH dose and mortality. The hospital mortality was 60% with a SMR of 1.1 (95% confidence interval 0.90-1.40): age and hyperlactatemia, rather than CVVH-characteristics and citrate accumulation, predicted mortality in multivariable analysis. Conclusion In critically ill, patients with AKI at high risk of bleeding, CVVH with citrate-containing replacement solution is safe and efficacious. The risk for citrate accumulation is 9% and best predicted by levels of transaminases. It carries, when citrate is discontinued, no attributable mortality.
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Affiliation(s)
- Shaikh A Nurmohamed
- Departments of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands.
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Oudemans-van Straaten HM, Ostermann M. Bench-to-bedside review: Citrate for continuous renal replacement therapy, from science to practice. Crit Care 2012; 16:249. [PMID: 23216871 PMCID: PMC3672558 DOI: 10.1186/cc11645] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
To prevent clotting in the extracorporeal circuit during continuous renal replacement therapy (CRRT) anticoagulation is required. Heparin is still the most commonly used anticoagulant. However, heparins increase the risk of bleeding, especially in critically ill patients. Evidence has accumulated that regional anticoagulation of the CRRT circuit with citrate is feasible and safe. Compared to heparin, citrate anticoagulation reduces the risk of bleeding and requirement for blood products, not only in patients with coagulopathy, but also in those without. Metabolic complications are largely prevented by the use of a strict protocol, comprehensive training and integrated citrate software. Recent studies indicate that citrate can even be used in patients with significant liver disease provided that monitoring is intensified and the dose is carefully adjusted. Since the citric acid cycle is oxygen dependent, patients at greatest risk of accumulation seem to be those with persistent lactic acidosis due to poor tissue perfusion. The use of citrate may also be associated with less inflammation due to hypocalcemia-induced suppression of intracellular signaling at the membrane and avoidance of heparin, which may have proinflammatory properties. Whether these beneficial effects increase patient survival needs to be confirmed. However, other benefits are the reason that citrate should become the first choice anticoagulant for CRRT provided that its safe use can be guaranteed.
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Affiliation(s)
| | - Marlies Ostermann
- King's College London, Guy's and St Thomas' Hospital, Department of Critical Care and Nephrology, London SE1 7EH, UK
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Regional citrate anticoagulation in patients with liver failure--time for a rethink? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:153. [PMID: 22985662 PMCID: PMC3682254 DOI: 10.1186/cc11492] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) has become increasingly attractive in recent years due to its favourable low bleeding risk profile. Its use in liver failure, however, has been limited due to the risk of citrate accumulation and toxicity. In the previous issue of Critical Care, Schultheiss and colleagues look at CRRT using RCA in liver failure patients. They demonstrate that citrate accumulation can be predicted using the total calcium (Catot) to ionised calcium (Caion) ratio (Catot/Caion), and determine that despite the occurrence of significant citrate accumulation, the effects of citrate accumulation are not as severe as might have been expected. This study raises interesting prospects with regard to RCA use in liver failure, and we postulate that citrate may have a role as a prognostic marker of metabolic capacity much as in the way of lactate and methacetin. However, further studies are warranted, in particular examining its application in subgroups of liver failure (chronic, acute, hyperacute and subacute), before its use becomes commonplace.
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Morabito S, Pistolesi V, Tritapepe L, Zeppilli L, Polistena F, Fiaccadori E, Pierucci A. Regional citrate anticoagulation in CVVH: a new protocol combining citrate solution with a phosphate-containing replacement fluid. Hemodial Int 2012; 17:313-20. [PMID: 22882732 PMCID: PMC3638367 DOI: 10.1111/j.1542-4758.2012.00730.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Regional citrate anticoagulation (RCA) is a valid anticoagulation method in continuous renal replacement therapies (CRRT) and different combination of citrate and CRRT solutions can affect acid-base balance. Regardless of the anticoagulation protocol, hypophosphatemia occurs frequently in CRRT. In this case report, we evaluated safety and effects on acid-base balance of a new RCA- continuous veno-venous hemofiltration (CVVH) protocol using an 18 mmol/L citrate solution combined with a phosphate-containing replacement fluid. In our center, RCA-CVVH is routinely performed with a 12 mmol/L citrate solution and a postdilution replacement fluid with bicarbonate (protocol A). In case of persistent acidosis, not related to citrate accumulation, bicarbonate infusion is scheduled. In order to optimize buffers balance, a new protocol has been designed using recently introduced solutions: 18 mmol/L citrate solution, phosphate-containing postdilution replacement fluid with bicarbonate (protocol B). In a cardiac surgery patient with acute kidney injury, acid-base status and electrolytes have been evaluated comparing protocol A (five circuits, 301 hours) vs. protocol B (two circuits, 97 hours): pH 7.39 ± 0.03 vs. 7.44 ± 0.03 (P < 0.0001), bicarbonate 22.3 ± 1.8 vs. 22.6 ± 1.4 mmol/L (NS), Base excess −2.8 ± 2.1 vs. −1.6 ± 1.2 (P = 0.007), phosphate 0.85 ± 0.2 vs. 1.3 ± 0.5 mmol/L (P = 0.027). Protocol A required bicarbonate and sodium phosphate infusion (8.9 ± 2.8 mmol/h and 5 g/day, respectively) while protocol B allowed to stop both supplementations. In comparison to protocol A, protocol B allowed to adequately control acid-base status without additional bicarbonate infusion and in absence of alkalosis, despite the use of a standard bicarbonate concentration replacement solution. Furthermore, the combination of a phosphate-containing replacement fluid appeared effective to prevent hypophosphatemia.
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Affiliation(s)
- Santo Morabito
- Department of Nephrology and Urology, Hemodialysis Unit, Umberto I, Policlinico di Roma, Sapienza University, Rome, Italy.
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Ratio of total-to-ionized calcium and mortality risk. Nat Rev Nephrol 2012. [DOI: 10.1038/nrneph.2012.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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