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Honoré PM, Rimmelé T, Joannes-Boyau O. Citrate anticoagulation for continuous renal replacement therapy. Intensive Care Med 2024:10.1007/s00134-024-07531-3. [PMID: 39037609 DOI: 10.1007/s00134-024-07531-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2024] [Indexed: 07/23/2024]
Affiliation(s)
- Patrick M Honoré
- ICU Department, CHU UCL Namur Godinne, UCL University, Campus Godinne, 1, Avenue Dr Gaston Therasse, 5530, Yvoir, Belgium.
- Faculty of Medicine and Member of the Experimental Research Laboratory Institute, Catholic Louvain Medical School, Brussels, Belgium.
| | - Thomas Rimmelé
- Anaesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- EA 74/26, Pathophysiology of Injury-Induced Immunosuppression, Hospices Civils de Lyon-Biomérieux-University Claude Bernard Lyon 1, Lyon, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie‑Réanimation Thoraco-abdominale, CMC Magellan, CHU de Bordeaux, Bordeaux, France
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Dimski T, Brandenburger T, Vollmer C, Kindgen-Milles D. A safe and effective protocol for postdilution hemofiltration with regional citrate anticoagulation. BMC Nephrol 2024; 25:218. [PMID: 38982339 PMCID: PMC11234626 DOI: 10.1186/s12882-024-03659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is recommended during continuous renal replacement therapy. Compared to systemic anticoagulation, RCA provides a longer filter lifespan with the risk of metabolic alkalosis and impaired calcium homeostasis. Surprisingly, most RCA protocols are designed for continuous veno-venous hemodialysis or hemodiafiltration. Effective protocols for continuous veno-venous hemofiltration (CVVH) are rare, although CVVH is a standard treatment for high-molecular-weight clearance. Therefore, we evaluated a new RCA protocol for postdilution CVVH. METHODS This is a monocentric prospective interventional study to evaluate a new RCA protocol for postdilution CVVH. We recruited surgical patients with stage III acute kidney injury who needed renal replacement therapy. We recorded dialysis and RCA data and hemodynamic and laboratory parameters during treatment sessions of 72 h. The primary endpoint was filter patency at 72 h. The major safety parameters were metabolic alkalosis and severe hypocalcemia at any time. RESULTS We included 38 patients who underwent 66 treatment sessions. The mean filter lifespan was 66 ± 12 h, and 44 of 66 (66%) filters were patent at 72 h. After censoring for non-CVVH-related cessation of treatment, 83% of all filters were patent at 72 h. The delivered dialysis dose was 28 ± 5 ml/kgBW/h. The serum levels of creatinine, urea and beta2-microglobulin decreased significantly from day 0 to day 3. Metabolic alkalosis occurred in one patient. An iCa++ below 1.0 mmol/L occurred in four patients. Citrate accumulation did not occur. CONCLUSIONS We describe a safe, effective, and easy-to-use RCA protocol for postdilution CVVH. This protocol provides a long and sustained filter lifespan without serious adverse effects. The risk of metabolic alkalosis and hypocalcemia is low. Using this protocol, a recommended dialysis dose can be safely administered with effective clearance of low- and middle-molecular-weight molecules. TRIAL REGISTRATION The study was approved by the medical ethics committee of Heinrich-Heine University Duesseldorf (No. 2018-82KFogU). The trial was registered in the local study register of the university (No: 2018044660) on 07/04/2018 and was retrospectively registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03969966) on 31/05/2019.
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Affiliation(s)
- Thomas Dimski
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany.
| | - Timo Brandenburger
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstr. 5, Duesseldorf, 40225, Germany
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Kunz JV, Hansmann H, Fähndrich M, Pigorsch M, Bethke N, Peters H, Krüger A, Schroeder T, Marcy F, Magomedov A, Müller-Redetzky H, Eckardt KU, Khadzhynov D, Enghard P. Standard vs. carbone dioxide adapted kidney replacement therapy in hypercapnic ARDS patients: a randomized controlled pilot trial (BigBIC). Crit Care 2024; 28:198. [PMID: 38863072 PMCID: PMC11167756 DOI: 10.1186/s13054-024-04979-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Current continuous kidney replacement therapy (CKRT) protocols ignore physiological renal compensation for hypercapnia. This study aimed to explore feasibility, safety, and clinical benefits of pCO2-adapted CKRT for hypercapnic acute respiratory distress syndrome (ARDS) patients with indication for CKRT. METHODS We enrolled mechanically ventilated hypercapnic ARDS patients (pCO2 > 7.33 kPa) receiving regional citrate anticoagulation (RCA) based CKRT in a prospective, randomized-controlled pilot-study across five intensive care units at the Charité-Universitätsmedizin Berlin, Germany. Patients were randomly assigned 1:1 to the control group with bicarbonate targeted to 24 mmol/l or pCO2-adapted-CKRT with target bicarbonate corresponding to physiological renal compensation. Study duration was six days. Primary outcome was bicarbonate after 72 h. Secondary endpoints included safety and clinical endpoints. Endpoints were assessed in all patients receiving treatment. RESULTS From September 2021 to May 2023 40 patients (80% male) were enrolled. 19 patients were randomized to the control group, 21 patients were randomized to pCO2-adapted-CKRT. Five patients were excluded before receiving treatment: three in the control group (consent withdrawal, lack of inclusion criteria fulfillment (n = 2)) and two in the intervention group (lack of inclusion criteria fulfillment, sudden unexpected death) and were therefore not included in the analysis. Median plasma bicarbonate 72 h after randomization was significantly higher in the intervention group (30.70 mmol/l (IQR 29.48; 31.93)) than in the control group (26.40 mmol/l (IQR 25.63; 26.88); p < 0.0001). More patients in the intervention group received lung protective ventilation defined as tidal volume < 8 ml/kg predicted body weight. Thirty-day mortality was 10/16 (63%) in the control group vs. 8/19 (42%) in the intervention group (p = 0.26). CONCLUSION Tailoring CKRT to physiological renal compensation of respiratory acidosis appears feasible and safe with the potential to improve patient care in hypercapnic ARDS. TRIAL REGISTRATION The trial was registered in the German Clinical Trials Register (DRKS00026177) on September 9, 2021 and is now closed.
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Affiliation(s)
- Julius Valentin Kunz
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Helena Hansmann
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Mareike Fähndrich
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mareen Pigorsch
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Nicole Bethke
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Department of Nephrology, Vivantes Klinikum Friedrichshain, Berlin, Germany
| | - Harm Peters
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anne Krüger
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tim Schroeder
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Florian Marcy
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Abakar Magomedov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Holger Müller-Redetzky
- Department of Infectious Diseases, Pneumology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Charité-Platz 1, 10117, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- Kuratorium for Dialysis and Transplantation (KfH) Renal Unit Berlin-Mitte, Große Hamburger Str. 5-11, Berlin, Germany
| | - Philipp Enghard
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
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Israni A, Goldfarb DS. Let's stop talking about 'citrate toxicity'. Curr Opin Nephrol Hypertens 2024; 33:181-185. [PMID: 37962170 DOI: 10.1097/mnh.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is a vital medical intervention used in critically ill patients with acute kidney injury (AKI). One of the key components of adequate clearance with CRRT is the use of anticoagulants to prevent clotting of the extracorporeal circuit. Regional citrate anticoagulation is the most often recommended modality. The term 'citrate toxicity' is used to describe potential adverse effects of accumulation of citrate and subsequent hypocalcemia. However, citrate is itself not inherently toxic. The term and diagnosis of citrate toxicity are questioned in this review. RECENT FINDINGS Citrate is being increasingly used for regional anticoagulation of the CRRT circuit. Citrate accumulation is infrequent and can cause hypocalcemia and metabolic alkalosis, which are potential adverse effects. Citrate itself, however, is not a toxic molecule. The term 'citrate toxicity' has been used to denote hypocalcemia and metabolic acidosis. However, citrate administration is well known to cause systemic and urinary alkalinization and under certain circumstances, metabolic alkalosis, but is not associated itself with any 'toxic' effects.We review the existing literature and debunk the perceived toxicity of citrate. We delve into the metabolism and clearance of citrate and question current data suggesting metabolic acidosis occurs as the result of citrate accumulation. SUMMARY In conclusion, this article calls into question prevailing concerns about 'citrate toxicity'. We emphasize the need for a more nuanced understanding of its safety profile. We recommend discarding the term 'citrate toxicity' in favor of another frequently used, but more meaningful term: 'citrate accumulation'.
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Affiliation(s)
- Avantika Israni
- Nephrology Division, NYU Grossman School of Medicine and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA
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Szamosfalvi B, Heung M. Citrate Anticoagulation for CKRT with Liver Failure: Ready for Prime Time? Clin J Am Soc Nephrol 2024; 19:139-141. [PMID: 38109078 PMCID: PMC10861106 DOI: 10.2215/cjn.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
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Bai M, Yu Y, Zhao L, Tian X, Zhou M, Jiao J, Liu Y, Li Y, Yue Y, Wei L, Jing R, Li Y, Ma F, Liang Y, Sun S. Regional Citrate Anticoagulation versus No Anticoagulation for CKRT in Patients with Liver Failure with Increased Bleeding Risk. Clin J Am Soc Nephrol 2024; 19:151-160. [PMID: 37990929 PMCID: PMC10861105 DOI: 10.2215/cjn.0000000000000351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients. METHODS Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure. RESULTS Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours. CONCLUSIONS For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .
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Affiliation(s)
- Ming Bai
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Yu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijuan Zhao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Xiujuan Tian
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Meilan Zhou
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Jing Jiao
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yi Liu
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yajuan Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yuan Yue
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lei Wei
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Rui Jing
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yangping Li
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Feng Ma
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ying Liang
- Department of Health Statistics, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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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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Guo L, Hu Y, Zeng Q, Yang X. Factors affecting continuous renal replacement therapy duration in critically ill patients: A retrospective study. Ther Apher Dial 2023; 27:898-908. [PMID: 37308250 DOI: 10.1111/1744-9987.14024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION This study aimed to analyze the factors affecting continuous renal replacement therapy (CRRT) duration in critically ill patients and provide a reference for clinical treatment. MATERIAL AND METHODS We divided patients into regional citrate anti-coagulation (RCA) and low-molecular-weight-heparin (LMWH) groups according to the anti-coagulation method and collected the relevant data, to analyze the factors associated with CRRT time. RESULTS Compared with the LMWH group, the RCA group had a longer mean treatment time (55.36 ± 22.57 vs. 37.65 ± 27.09 h, p < 0.001), lower transmembrane pressure, and lower filter pressure, regardless of vascular access site. Multivariable linear regression analysis showed a significant correlation between anti-coagulation patterns, filter pressure at CRRT discontinuation, nurses' level of intensive care unit experience, pre-machine fibrinogen level, and CRRT time. CONCLUSION Anti-coagulation is the most important factor affecting CRRT duration. Filter pressure, nurses' level of intensive care unit experience, and fibrinogen level also affecting CRRT duration.
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Affiliation(s)
- Litao Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yandong Hu
- Department of Critical Care Medicine, Sanmenxia Central Hospital, Henan, China
| | - Qinjing Zeng
- Department of Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xinjuan Yang
- Department of Critical Care Medicine, Sanmenxia Central Hospital, Henan, China
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Di Mario F, Sabatino A, Regolisti G, Pacchiarini MC, Greco P, Maccari C, Vizzini G, Italiano C, Pistolesi V, Morabito S, Fiaccadori E. Simplified regional citrate anticoagulation protocol for CVVH, CVVHDF and SLED focused on the prevention of KRT-related hypophosphatemia while optimizing acid-base balance. Nephrol Dial Transplant 2023; 38:2298-2309. [PMID: 37037771 PMCID: PMC10547235 DOI: 10.1093/ndt/gfad068] [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: 10/20/2022] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Hypophosphatemia is a common electrolyte disorder in critically ill patients undergoing prolonged kidney replacement therapy (KRT). We evaluated the efficacy and safety of a simplified regional citrate anticoagulation (RCA) protocol for continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF) and sustained low-efficiency dialysis filtration (SLED-f). We aimed at preventing KRT-related hypophosphatemia while optimizing acid-base equilibrium. METHODS KRT was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 filters (ST 150, 1.5 m2, Baxter), combining a 18 mmol/L pre-dilution citrate solution (Regiocit 18/0, Baxter) with a phosphate-containing solution (HPO42- 1.0 mmol/L, HCO3- 22.0 mmol/L; Biphozyl, Baxter). When needed, phosphate loss was replaced with sodium glycerophosphate pentahydrate (Glycophos™ 20 mmol/20 mL, Fresenius Kabi Norge AS, Halden, Norway). Serum citrate measurements were scheduled during each treatment. We analyzed data from three consecutive daily 8-h SLED-f sessions, as well as single 72-h CVVH or 72-h CVVHDF sessions. We used analysis of variance (ANOVA) for repeated measures to evaluate differences in variables means (i.e. serum phosphate, citrate). Because some patients received phosphate supplementation, we performed analysis of covariance (ANCOVA) for repeated measures modelling phosphate supplementation as a covariate. RESULTS Forty-seven patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) requiring KRT were included [11 CVVH, 11 CVVHDF and 25 SLED-f sessions; mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score 25 ± 7.0]. Interruptions for irreversible filter clotting were negligible. The overall incidence of hypophosphatemia (s-P levels <2.5 mg/dL) was 6.6%, and s-P levels were kept in the normality range irrespective of baseline values and the KRT modality. The acid-base balance was preserved, with no episode of citrate accumulation. CONCLUSIONS Our data obtained with a new simplified RCA protocol suggest that it is effective and safe for CVVH, CVVHDF and SLED, allowing to prevent KRT-related hypophosphatemia and maintain the acid-base balance without citrate accumulation. TRIAL REGISTRATION NCT03976440 (registered 6 June 2019).
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Alice Sabatino
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Caterina Maccari
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Vizzini
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Chiara Italiano
- Laboratorio di Immunopatologia Renale “Luigi Migone”, Università degli Studi di Parma, Parma, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, “Sapienza” Università̀ di Roma, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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10
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Brunoni B, Zadek F, Mulazzani F, Verza G, Marrazzo F, Spina S, Protti A, Fumagalli R, Langer T. Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review. Blood Purif 2023; 52:802-811. [PMID: 37673054 DOI: 10.1159/000531953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/29/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Metformin intoxication causes lactic acidosis by inhibiting Krebs' cycle and oxidative phosphorylation. Continuous renal replacement therapy (CRRT) is recommended for metformin removal in critically ill patients. According to current guidelines, regional citrate anticoagulation (RCA) is the first-line strategy. However, since metformin also inhibits citrate metabolism, a risk of citrate accumulation could be hypothesized. In the present study, we monitored the potential citrate accumulation in metformin-associated lactic acidosis (MALA) patients treated with CRRT and RCA using the physical-chemical approach to acid-base interpretation. METHODS We collected a case series of 3 patients with MALA. Patients were treated with continuous venovenous hemofiltration (CVVH), and RCA was performed with diluted citrate solution. Citrate accumulation was monitored through two methods: the ratio between total and ionized plasma calcium concentrations (T/I calcium ratio) above 2.5 and the strong ion gap (SIG) to identify an increased concentration of unmeasured anions. Lastly, a mathematical model was developed to estimate the expected citrate accumulation during CVVH and RCA. RESULTS All 3 patients showed a resolution of MALA after the treatment with CVVH. The T/I calcium ratio was consistently below 2.5, and SIG decreased, reaching values lower than 6 mEq/L after 48 h of CVVH treatment. According to the mathematical model, the estimated SIG without citrate metabolism should have been around 21 mEq/L due to citrate accumulation. CONCLUSIONS In our clinical management, no signs of citrate accumulation were recorded in MALA patients during treatment with CVVH and RCA. Our data support the safe use of diluted citrate to perform RCA during metformin intoxication.
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Affiliation(s)
- Beatrice Brunoni
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesca Mulazzani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giovanni Verza
- INFN, Sezione di Padova, Padova, Italy
- Dipartimento di Fisica e Astronomia "G. Galilei", Università Degli Studi di Padova, Padova, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Stefano Spina
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milano, Italy
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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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12
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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13
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Zhou Z, Liu C, Yang Y, Wang F, Zhang L, Fu P. Anticoagulation options for continuous renal replacement therapy in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials. Crit Care 2023; 27:222. [PMID: 37287084 DOI: 10.1186/s13054-023-04519-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/02/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is a widely used standard therapy for critically ill patients with acute kidney injury (AKI). Despite its effectiveness, treatment is often interrupted due to clot formation in the extracorporeal circuits. Anticoagulation is a crucial strategy for preventing extracorporeal circuit clotting during CRRT. While various anticoagulation options are available, there were still no studies synthetically comparing the efficacy and safety of these anticoagulation options. METHODS Electronic databases (PubMed, Embase, Web of Science, and the Cochrane database) were searched from inception to October 31, 2022. All randomized controlled trials (RCTs) that examined the following outcomes were included: filter lifespan, all-cause mortality, length of stay, duration of CRRT, recovery of kidney function, adverse events and costs. RESULTS Thirty-seven RCTs from 38 articles, comprising 2648 participants with 14 comparisons, were included in this network meta-analysis (NMA). Unfractionated heparin (UFH) and regional citrate anticoagulation (RCA) are the most frequently used anticoagulants. Compared to UFH, RCA was found to be more effective in prolonging filter lifespan (MD 12.0, 95% CI 3.8 to 20.2) and reducing the risk of bleeding. Regional-UFH plus Prostaglandin I2 (Regional-UFH + PGI2) appeared to outperform RCA (MD 37.0, 95% CI 12.0 to 62.0), LMWH (MD 41.3, 95% CI 15.6 to 67.0), and other evaluated anticoagulation options in prolonging filter lifespan. However, only a single included RCT with 46 participants had evaluated Regional-UFH + PGI2. No statistically significant difference was observed in terms of length of ICU stay, all-cause mortality, duration of CRRT, recovery of kidney function, and adverse events among most evaluated anticoagulation options. CONCLUSIONS Compared to UFH, RCA is the preferred anticoagulant for critically ill patients requiring CRRT. The SUCRA analysis and forest plot of Regional-UFH + PGI2 are limited, as only a single study was included. Additional high-quality studies are necessary before any recommendation of Regional-UFH + PGI2. Further larger high-quality RCTs are desirable to strengthen the evidence on the best choice of anticoagulation options to reduce all-cause mortality and adverse events and promote the recovery of kidney function. Trial registration The protocol of this network meta-analysis was registered on PROSPERO ( CRD42022360263 ). Registered 26 September 2022.
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Affiliation(s)
- Zhifeng Zhou
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Chen Liu
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yingying Yang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Fang Wang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Ling Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Ping Fu
- Department of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, 610041, China
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Liu SY, Xu SY, Yin L, Yang T, Jin K, Zhang QB, Sun F, Tan DY, Xin TY, Chen YG, Zhao XD, Yu XZ, Xu J. Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus. Mil Med Res 2023; 10:23. [PMID: 37248514 DOI: 10.1186/s40779-023-00457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is widely used for treating critically-ill patients in the emergency department in China. Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT. Regional citrate anticoagulation (RCA) has been shown to potentially be safer and more effective and is now recommended as the preferred anticoagulant method for CRRT. However, there is still a lack of unified standards for RCA management in the world, and there are many problems in using this method in clinical practice. The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues, including the advantages and disadvantages of RCA in CRRT anticoagulation, the principle of RCA, parameter settings for RCA, monitoring of RCA (mainly metabolic acid-base disorders), and special issues during RCA. Based on the latest available research evidence as well as the paneled experts' clinical experience, considering the generalizability, suitability, and potential resource utilization, while also balancing clinical advantages and disadvantages, a total of 16 guideline recommendations were formed from the experts' consensus.
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Affiliation(s)
- Shu-Yuan Liu
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Sheng-Yong Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lu Yin
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen, 518000, China
| | - Ting Yang
- Emergency Department, The First Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Kui Jin
- Emergency Department, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230001, China
| | - Qiu-Bin Zhang
- Emergency Department, The Second Affiliated Hospital of Hainan Medical College, Haikou, 570100, China
| | - Feng Sun
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Ding-Yu Tan
- Emergency Department, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, 225001, China
| | - Tian-Yu Xin
- Emergency Department, The Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Yu-Guo Chen
- Emergency Department and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, 100005, China.
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Jinan, 100005, China.
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, 100005, China.
| | - Xiao-Dong Zhao
- Emergency Department, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China.
| | - Xue-Zhong Yu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Jun Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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15
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Jacobs R, Verbrugghe W, Dams K, Roelant E, Couttenye MM, Devroey D, Jorens P. Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Life (Basel) 2023; 13:life13051198. [PMID: 37240843 DOI: 10.3390/life13051198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. METHODS Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. RESULTS Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110). CONCLUSION regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.
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Affiliation(s)
- Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Walter Verbrugghe
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Karolien Dams
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Marie Madeleine Couttenye
- Department of Nephrology and Hypertension, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
| | - Dirk Devroey
- Deparmtment of Family Medicine and Chronic Care, Faculty of Medicine and Framacy, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, 2650 Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), 2000 Antwerpen, Belgium
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16
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González-Fernández M, Quílez-Trasobares N, Barea-Mendoza JA, Molina-Collado Z, Arias-Verdú D, Barrueco-Francioni J, Seller-Pérez G, Herrera-Gutiérrez ME, Sánchez-Izquierdo Riera JA. Evaluation of the registry DIALYREG for the assessment of continuous renal replacement techniques in the critically ill patient. Sci Rep 2023; 13:6479. [PMID: 37081011 PMCID: PMC10117243 DOI: 10.1038/s41598-023-32795-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 04/03/2023] [Indexed: 04/22/2023] Open
Abstract
Continuous renal replacement techniques (CRRT) can induce complications and monitoring is crucial to ensure patient safety. We designed a prospective multicenter observational and descriptive study using the DIALYREG registry, an online database located on a REDCap web-based platform that allows real-time data analysis. Our main objective was to identify CRRT-related complications in our intensive care units (ICUs) and implement security measures accordingly. From January 2019 to December 2020, we included 323 patients with admission diagnoses of medical illness (54%), sepsis (24%), postoperative care (20%), and trauma (2%). CRRT indications were homeostasis (42%), oliguria (26%), fluid overload (15%), and hemodynamic optimization (13%). The median initial therapy dose was 30 ml/kg/h (IQR 25-40), and dynamic adjustment was performed in 61% of the treatments. Sets were anticoagulated with heparin (40%), citrate (38%) or no anticoagulation (22%). Citrate anticoagulation had several advantages: more frequent dynamic CRRT dose adjustment (77% vs. 58% with heparin and 56% without anticoagulation, p < 0.05), longer duration of set (median of 55 h, IQR 24-72 vs. 23 h, IQR 12-48 with heparin and 12 h, IQR 12-31 without anticoagulation, p < 0.05), less clotting of the set (26% vs. 46.7% with heparin, p < 0.05), and lower incidence of hypophosphatemia (1% citrate vs. 6% with heparin and 5% without anticoagulation). It was also safe and effective in subgroup analysis of patients with liver disease or sepsis. The main global complications were hypothermia (16%), hypophosphatemia (13%) and metabolic acidosis (10%). Weaning of the therapy was achieved through early discontinuation (56%), nocturnal therapy transition (26%) and progressive SLED (18%). 52% of the patients were discharged from the hospital, while 43% died in the ICU and 5% died during hospitalization. We can conclude that the DIALYREG registry is a feasible tool for real-time control of CRRT in our ICU.
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Affiliation(s)
- M González-Fernández
- Department of Intensive Care Medicine, University Hospital 12 de Octubre, Madrid, Spain
| | - N Quílez-Trasobares
- Department of Intensive Care Medicine, University Hospital 12 de Octubre, Madrid, Spain
| | - J A Barea-Mendoza
- Department of Intensive Care Medicine, University Hospital 12 de Octubre, Madrid, Spain
| | - Z Molina-Collado
- Department of Intensive Care Medicine, University Hospital 12 de Octubre, Madrid, Spain
| | - D Arias-Verdú
- Department of Intensive Care Medicine, Regional University Hospital of Malaga, Malaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - J Barrueco-Francioni
- Department of Intensive Care Medicine, Regional University Hospital of Malaga, Malaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - G Seller-Pérez
- Department of Intensive Care Medicine, Regional University Hospital of Malaga, Malaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - M E Herrera-Gutiérrez
- Department of Intensive Care Medicine, Regional University Hospital of Malaga, Malaga, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.
- Departamento de Medicina y Dermatología, University of Malaga, Malaga, Spain.
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Mendibaev MS, Rabotinsky SE. Pharmacological methods for blood stabilization in the extracorporeal circuit (review of literature). MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2023. [DOI: 10.24884/2078-5658-2023-20-1-81-88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
We summarize the possible benefits and risks of using various anticoagulants during hemoperfusion. Clotting in the extracorporeal circuit can lead to a decrease in the effectiveness of therapy, additional workload, risk to the patient and economic losses. At the same time, relatively excessive anticoagulation against the background of existing hemostasis disorders can lead to severe hemorrhagic complications, which in turn worsen the prognosis of patients. The article describes the causes of heparin resistance, the main techniques for overcoming it, and provides practical guidelines for anticoagulant therapy during hemoperfusion. It is well known that routine methods of monitoring hemostasis (such as platelet count, activated partial thromboplastin time) are unable to assess the balance of pro/anticoagulants. The authors have proposed a reasonable personalized approach to anticoagulant therapy of extracorporeal blood purification depending on the pathology in patient and thromboelastography (TEG) data, and antithrombin III levels.
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18
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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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19
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Qi W, Liu J, Li A. Regional Citrate Anticoagulation or Heparin Anticoagulation for Renal Replacement Therapy in Patients With Liver Failure: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231174001. [PMID: 37186766 DOI: 10.1177/10760296231174001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
In patients with liver failure complicated by acute kidney injury, renal replacement therapy (RRT) is often required to improve the internal environment. The use of anticoagulants for RRT in patients with liver failure remains controversial. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for studies. The methodological quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies. A meta-analysis was performed using R software (version 3.5.1) and Review Manager (version 5.3.5). During RRT, 348 patients from 9 studies received regional citrate anticoagulation (RCA), and 127 patients from 5 studies received heparin anticoagulation (including heparin and LMWH). Among patients who received RCA, the incidence of citrate accumulation, metabolic acidosis, and metabolic alkalosis were 5.3% (95% confidence interval [CI]: 0%-25.3%), 26.4% (95% CI: 0-76.9), and 1.8% (95% CI: 0-6.8), respectively. The potassium, phosphorus, total bilirubin (TBIL), and creatinine levels were lower, whereas the serum pH, bicarbonate, base excess levels, and total calcium/ionized calcium ratio were higher after treatment than before treatment. Among patients who received heparin anticoagulation, the TBIL levels were lower, whereas the activated partial thromboplastin clotting time and D-dimer levels were higher after treatment than before treatment. The mortality rates in the RCA and heparin anticoagulation groups were 58.9% (95% CI: 39.2-77.3) and 47.4% (95% CI: 31.1-63.7), respectively. No statistical difference in mortality was observed between the 2 groups. For patients with liver failure, the administration of RCA or heparin for anticoagulation during RRT under strict monitoring may be safe and effective.
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Affiliation(s)
- Wenqian Qi
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Liu
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ang Li
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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20
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Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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21
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Li L, Bai M, Zhang Q, Sun S. Characteristics and predictors of ICU-mortality in critically ill patients with hyperlactatemia requiring CRRT: A retrospective cohort study. Int J Artif Organs 2022; 45:973-980. [PMID: 36151706 DOI: 10.1177/03913988221126728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hyperlactatemia is a common complication in critically ill patients with high morbidity and mortality. Hyperlactatemia patients who require continuous renal replacement therapy (CRRT) constitute a subgroup with increased mortality risk. The clinical significance of serum lactate in these patients was not well understood and clearance of lactate using CRRT shown no survival benefits. The aim of this study is to investigate the incidence and non-lactate risk factors for ICU mortality in hyperlactatemia patients who underwent CRRT. METHOD Hyperlactatemia patients with a serum lactate level >2 μmol/L who underwent CRRT between January, 2014 and May, 2021 were retrospectively investigated. Demographic characteristics and clinical data were collected from the electronic medical record system. The primary endpoint was predictors for ICU mortality which were identified by using multivariate logistic regression analysis. RESULTS A total of 178 eligible patients were finally included with a mean age of 56.6 ± 17.9 years and a median APACHE II score of 18 (IQR (14-22)). The multivariate regression results showed that male gender (OR 0.55 (95%CI 0.27-1.12), p = 0.1), mechanical ventilation (OR 2.60 (95%CI 1.27-5.34), p = 0.008), history of hypertension (OR 2.40 (95%CI 1.12-5.14), p = 0.02), SOFA score (OR 1.16 (95%CI 1.05-1.28), p = 0.002), AST (OR 1.0005 (95%CI 0.99-1.001), p = 0.08), and PT (OR 1.08 (95%CI 0.99-1.17), p = 0.06) were independently associated with ICU mortality. After adjusting for age, illness severity (APACHE II score), and serum lactate level, the statistical significances of SOFA score (OR 1.16 (95%CI 1.04-1.29), p = 0.005), hypertension (OR 2.25 (95%CI 1.02-4.95), p = 0.04), and mechanical ventilation (OR 2.54 (95%CI 1.22-5.25), p = 0.01) were not affected. The overall ICU mortality was 58.4% (104/178). CONCLUSION The hyperlactatemia patients who underwent CRRT were at increased ICU mortality. Gender, AST, PT, SOFA score, history of hypertension, and mechanical ventilation were independent predictors for ICU mortality. Future studies with prospectively design, large sample size, and subgroup analyses are warranted to validate these findings.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiaona Zhang
- Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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22
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Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting. Nephrourol Mon 2022. [DOI: 10.5812/numonthly-124164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is contraindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sustained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyzers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication.
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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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24
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Hu F, Sun Y, Bai K, Liu C. Clinical application of regional citrate anticoagulation for continuous renal replacement therapy in children with liver injury. Front Pediatr 2022; 10:847443. [PMID: 36304531 PMCID: PMC9592741 DOI: 10.3389/fped.2022.847443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 09/06/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is increasingly used for continuous renal replacement therapy (CRRT) in children, but it is rarely used in children with liver injury, especially liver failure (LF). We analyze this issue through the following research. METHODS We retrospectively analyzed 75 children with liver injury who underwent RCA-CRRT in the Pediatric Intensive Care Unit (PICU) of Children's Hospital of Chongqing Medical University. The patients were divided into the LF group and liver dysfunction (LD) group. The two groups were compared to evaluate the clinical safety and efficacy of RCA-CRRT in children with liver injury and to explore RCA-CRRT management strategies, in terms of the following indicators: the incidence of bleeding, clotting, citrate accumulation (CA), acid-base imbalance, and electrolyte disturbance, as well as filter lifespans, changes in biochemical indicators, and CRRT parameters adjustment. RESULTS The total incidence of CA (TCA) and persistent CA (PCA) in the LF group were significantly higher than those in the LD group (38.6 vs. 16.2%, p < 0.001; 8.4 vs. 1.5%, p < 0.001); and the CA incidence was significantly reduced after adjustment both in the LF (38.6 vs. 8.4%, p < 0.001) and LD groups (16.2 vs. 1.5%, p < 0.001). The incidence of hypocalcemia was significantly higher in the LF group than in the LD group either before (34.9 vs. 8.8%, p < 0.001) or after treatment (12.0 vs. 0%, p < 0.001). The speed of the blood and citrate pumps after adjustment was lower than the initial setting values in both the LF and LD groups. The dialysis speed plus replacement speed were higher than the initial settings parameters. CONCLUSION For children undergoing RCA-CRRT, the risks of CA and hypocalcemia are significantly higher in children with liver failure than those with liver dysfunction, but through the proper adjustment of the protocol, RCA-CRRT can still be safely and effectively approached for children with LD and even LF.
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Affiliation(s)
- Fang Hu
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,The People's Hospital of Qijiang District, Chongqing, China
| | - Yuelin Sun
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ke Bai
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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25
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Efficacy and complications of regional citrate anticoagulation during continuous renal replacement therapy in critically ill patients with COVID-19. J Crit Care 2021; 67:126-131. [PMID: 34768173 PMCID: PMC8576341 DOI: 10.1016/j.jcrc.2021.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 12/23/2022]
Abstract
Background We compared filter survival and citrate-induced complications during continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in COVID-19 and Non-COVID-19 patients. Methods In this retrospective study we included all consecutive adult patients (n = 97) treated with RCA-CRRT. Efficacy and complications of RCA-CRRT were compared between COVID-19 and Non-COVID-19 patients. Results Mean filter run-time was significantly higher in COVID-19 patients compared to Non-COVID-19 patients (68.4 (95%CI 67.0–69.9) vs. 65.2 (95%CI 63.2–67.2) hours, respectively; log-rank 0.014). COVID-19 patients showed significantly higher activated partial thromboplastin time (aPTT) throughout the CRRT due to intensified systemic anticoagulation compared to Non-COVID-19 patients (54 (IQR 45–61) vs. 47 (IQR 41–58) seconds, respectively; p < 0.001). A significantly higher incidence of metabolic alkalosis, hypercalcemia and hypernatremia, consistent with reduced filter patency and citrate overload, was observed in COVID-19 patients compared to Non-COVID-19 patients (19.1% vs. 12.7%, respectively; p = 0.04). These metabolic disarrangements were resistant to per-protocol adjustments and disappeared after replacement of the CRRT-filter. Conclusions RCA-CRRT in COVID-19 patients with intensified systemic anticoagulation provides an adequate filter lifespan. However, close monitoring of the acid-base balance appears warranted, as these patients tend to develop reduced filter patency leading to a higher incidence of citrate overload and metabolic disturbances. Trial registration (local authority) EA1/285/20 (Ethikkommission der Charité - Universitätsmedizin Berlin); date of registration 08.10.2020.
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26
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Zhang W, Bai M, Zhang L, Yu Y, Li Y, Zhao L, Yue Y, Li Y, Zhang M, Fu P, Sun S, Chen X. Development and External Validation of a Model for Predicting Sufficient Filter Lifespan in Anticoagulation-Free Continuous Renal Replacement Therapy Patients. Blood Purif 2021; 51:668-678. [PMID: 34673634 PMCID: PMC9501746 DOI: 10.1159/000519409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/18/2021] [Indexed: 02/05/2023]
Abstract
Background Anticoagulation-free continuous renal replacement therapy (CRRT) was recommended by the current clinical guideline for patients with increased bleeding risk and contraindications of citrate. Nevertheless, anticoagulation-free CRRT yielded heterogeneous filter lifespan. Furthermore, the specific cutoff values for traditional coagulation parameters to predict sufficient filter lifespan of anticoagulation-free CRRT have not yet been determined. The purpose of our present study was to develop and validate a model for predicting sufficient filter lifespan in anticoagulation-free CRRT patients. Methods Patients who underwent anticoagulation-free CRRT in our center between June 2013 and June 2019 were retrospectively included. The primary outcome was sufficient filter lifespan (≥24 h). Thirty-seven predictors were included for modeling based on their clinical significance and previous reports. The final model was developed by using multivariable logistic regression analysis and was validated in a separate external cohort. Results The development cohort included 170 patients. Sufficient filter lifespan was observed in 80 patients. Thirteen variables were independent predictors for sufficient filter lifespan by logistic regression: body temperature, mean arterial pressure, activated partial thromboplastin time, direct bilirubin, alkaline phosphatase, blood urea nitrogen, vasopressor use, body mass index, white blood cell, platelet count, D-dimer, uric acid, and pH. The area under the curve (AUC) of the stepwise model and internal validation model was 0.82 (95% confidence interval [CI] [0.76–0.88]) and 0.8 (95% CI [0.74–0.87]), respectively. The positive predictive value and the negative predictive value of the stepwise model were 0.77 and 0.79, respectively. The validation cohort included 44 eligible patients and the AUC of the external validation model was 0.82 (95% CI [0.69–0.96]). Conclusions The use of a prediction model instead of an assessment based only on coagulation parameters could facilitate the identification of the patients with filter lifespan of ≥24 h when they accepted anticoagulation-free CRRT.
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Affiliation(s)
- Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Ling Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yuan Yue
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Yajuan Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Min Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Fu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China
| | - Xiangmei Chen
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xian, China.,Nephrology Institute of the Chinese People's Liberation Army, Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
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27
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Warnar C, Faber E, Katinakis PA, Schermer T, Spronk PE. Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy. J Clin Monit Comput 2021; 36:871-877. [PMID: 33991270 DOI: 10.1007/s10877-021-00719-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.
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Affiliation(s)
- C Warnar
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - E Faber
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - P A Katinakis
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands
| | - T Schermer
- Department of Epidemiology, Gelre Hospitals, Apeldoorn , The Netherlands
| | - P E Spronk
- Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.,Expertise Center for Intensive Care Rehabilitation Apeldoorn - ExpIRA, Gelre Hospitals, Apeldoorn , The Netherlands
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Xin X, Tang J, Jia HM, Zhang TE, Zheng Y, Huang LF, Ding Q, Li JC, Guo SY, Li WX. Development of a Multivariable Prediction Model for Citrate Accumulation in Liver Transplant Patients Undergoing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2021; 51:111-121. [PMID: 33951630 DOI: 10.1159/000513947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with impaired citrate metabolism may experience citrate accumulation (CA), which causes life-threatening metabolic acidosis and hypocalcemia. CA poses a challenge for clinicians when deciding on the use of regional citrate anticoagulation (RCA) for patients with liver dysfunction. This study aimed to develop a prediction model integrating multiple clinical variables to assess the risk of CA in liver transplant patients. METHODS This single-center prospective cohort study included postoperative liver transplant patients who underwent continuous renal replacement therapy (CRRT) with RCA. The study end point was CA. A prediction model was developed using a generalized linear mixed-effect model based on the Akaike information criterion. The predictive values were assessed using the receiver operating characteristic curve and bootstrap resampling (times = 500) to estimate the area under the curve (AUC) and the corresponding 95% confidence interval (CI). A nomogram was used to visualize the model. RESULTS This study included 32 patients who underwent 133 CRRT sessions with RCA. CA occurred in 46 CRRT sessions. The model included lactate, norepinephrine >0.1 μg/kg/min, alanine aminotransferase, total bilirubin, and standard bicarbonate, which were tested before starting each CRRT session and body mass index, diabetes mellitus, and chronic kidney disease as predictors. The AUC of the model was 0.867 (95% CI 0.786-0.921), which was significantly higher than that of the single predictor (p < 0.05). A nomogram visualized the prediction model. CONCLUSIONS The prediction model integrating multiple clinical variables showed a good predictive value for CA. A nomogram visualized the model for easy application in clinical practice.
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Affiliation(s)
- Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Tang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui-Miao Jia
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tian-En Zhang
- Department of Health Science, Gettysburg College, Gettysburg, Pennsylvania, USA
| | - Yue Zheng
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li-Feng Huang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qi Ding
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jun-Cong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu-Yan Guo
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wen-Xiong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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29
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Rhee H, Berenger B, Mehta RL, Macedo E. Regional Citrate Anticoagulation for Continuous Kidney Replacement Therapy With Calcium-Containing Solutions: A Cohort Study. Am J Kidney Dis 2021; 78:550-559.e1. [PMID: 33798636 DOI: 10.1053/j.ajkd.2021.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Regional citrate anticoagulation (RCA) is the preferred anticoagulation method for continuous kidney replacement therapy (CKRT) recommended by KDIGO. Limited availability of calcium-free solutions often imposes challenges to the implementation of RCA for CKRT (RCA-CKRT). The principal purpose of this study was to characterize the outcomes of RCA-CKRT using calcium-containing solutions. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS We evaluated the safety and efficacy of RCA-CKRT with calcium-containing dialysate and replacement fluid used for 128 patients. A total of 571 filters and 1,227 days of CKRT were analyzed. EXPOSURES Liver disease, sepsis in the absence of liver disease, and sepsis with liver disease. OUTCOMES Filter life and metabolic complications per 100 CKRT days. ANALYTICAL APPROACH Linear mixed-effects model and generalized linear mixed-effects models. RESULTS The majority of patients were male (91; 71.1%), 32 (25%) had liver disease, and 29 (22.7%) had sepsis without liver disease. Median filter life was 50.0 (interquartile range, 22.0-118.0) hours, with a maximum of 322 hours, and was significantly lower (33.5 [interquartile range, 17.5-60.5] h) in patients with liver disease. Calcium-containing replacement solutions were used in 41.6% of all CKRT hours and reduced intravenous calcium requirements by 31.7%. Hypocalcemia (ionized calcium<0.85mmol/L) and hypercalcemia (total calcium>10.6mg/dL) were observed in 6.0 and 6.7 per 100 CKRT days, respectively. Citrate accumulation was observed in 13.3% of all patients and was associated with metabolic acidosis in 3.9%, which was not significantly different in patients with liver disease (9.3%; P = 0.2). LIMITATIONS Lack of control groups that used calcium-free dialysate and replacement solutions with RCA-CKRT. Possible overestimation of filter life from incomplete data on cause of filter failure. CONCLUSIONS Our study suggests that RCA-CKRT with calcium-containing solutions is feasible and safe in critically ill patients, including those with sepsis and liver disease.
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Affiliation(s)
- Harin Rhee
- Department of Medicine, University of California, San Diego, La Jolla, CA; Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Brendan Berenger
- Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, La Jolla, CA.
| | - Etienne Macedo
- Department of Medicine, University of California, San Diego, La Jolla, CA
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30
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Li L, Bai M, Zhang W, Zhao L, Yu Y, Sun S. Regional citrate anticoagulation versus low molecular weight heparin for CRRT in hyperlactatemia patients: A retrospective case-control study. Int J Artif Organs 2021; 45:343-350. [PMID: 33784842 DOI: 10.1177/03913988211003586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION There were controversial opinions on the use of regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) for continuous renal replacement therapy (CRRT) in hyperlactatemia patients, which was considered as one of the contraindications of citrate. The aim of our present study is to evaluate the efficacy and safety of RCA versus LMWH for CRRT in hyperlactatemia patients. METHODS Adult patients with hyperlactatemia who underwent RCA or LMWH CRRT in our center between January 2014 and March 2018 were retrospectively recruited. Filter lifespan, ultrafiltration, purification, bleeding, citrate accumulation, filter clot, and the infusion of blood production were evaluated as endpoints. RESULTS Of the 127 patients included in the original cohort, 81 and 46 accepted RCA and LMWH CRRT, respectively. The filter lifespan was significantly prolonged in the RCA group compared to the LMWH group (44.25 h [2 -83] vs. 24 h [4 -67], p < 0.001). The accumulated filter survival proportions were significantly improved in the RCA group compared to the LMWH group in the original cohort (p < 0.001) as well as the matched group (p < 0.001). The filters clotted more frequently in the LMWH group than in the RCA group in both of the original (52.2% vs 26.8%, p = 0.001) and matched cohort (58.6% vs 19.4%, p = 0.001). The bleeding complication was significantly reduced in the RCA group than in the LMWH group in the matched cohort (28.6% vs 4.5%, p = 0.04). CONCLUSION In critically ill patients with hyperlactatemia requiring CRRT, RCA is superior to LMWH in terms of filter lifespan and bleeding risk without significantly increased risk of citrate accumulation and citrate related metabolic complications. RCA most likely is a safe and effective anticoagulation method for CRRT in patients with hyperlactatemia.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, Shaanxi, China
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31
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Anstey CM, Russell FD. Measurement of the Concentration of Citrate in Human Biofluids in Patients Undergoing Continuous Renal Replacement Therapy Using Regional Citrate Anticoagulation: Application of a Two-Step Enzymatic Assay. Blood Purif 2021; 50:848-856. [PMID: 33550280 DOI: 10.1159/000513150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) is now commonly used to treat acute kidney injury in critically ill patients. The concentration of citrate is not routinely measured, with citrate accumulation and/or toxicity primarily assessed using surrogate measures. OBJECTIVES The aim of this study was to measure the concentration of citrate in plasma and ultrafiltrate in patients receiving CRRT with RCA using a modified commercial enzymatic assay. METHODS After meeting inclusion criteria, blood was sampled from 20 patients before, during, and after episodes of filtration. Using spectrophotometry, samples were tested for citrate concentration. Demographic and other clinical and biochemical data were also collected. Throughout, a 15 mmol/L solution of trisodium citrate was used as the prefilter anticoagulant. Results were analysed using STATA (v15.0) and presented as mean (SD), median (IQR), or simple proportion. Comparisons were made using either the Student t test or the Wilcoxon rank-sum test. Correlation was assessed using Pearson's r. RESULTS Twenty patients (17 males) were enrolled in the study. Mean (SD) age was 63.7 years (9.9). Median (IQR) ICU length of stay was 281 h (199, 422) with 85% undergoing intermittent positive pressure ventilation. Median APACHE 3 score was 95 (87, 117) with an overall 30% mortality rate. Median filtration time was 85 h (46, 149). No difference was found between pre- and post-filtration plasma citrate concentrations (79 µmol/L [50] vs. 71 µmol/L [42], p = 0.65). Mean citrate concentration during filtration was 508 µmol/L (221) with a maximum of 1,070 µmol/L. This was significantly higher than the pre/post levels (p < 0.001). CONCLUSIONS Plasma concentrations of citrate rose significantly during episodes of CRRT using RCA returning back to normal after cessation of treatment.
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Affiliation(s)
- Chris M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Queensland, Australia,
| | - Fraser D Russell
- Genecology Research Centre, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, Queensland, Australia
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Rajakumar A, Appuswamy E, Kaliamoorthy I, Rela M. Renal Dysfunction in Cirrhosis: Critical Care Management. Indian J Crit Care Med 2021; 25:207-214. [PMID: 33707901 PMCID: PMC7922436 DOI: 10.5005/jp-journals-10071-23721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Ellango Appuswamy
- Department of Liver Anaesthesia and Intensive Care, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Liver Transplantation and HPB Surgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
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33
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Sheng RM, Zhao WB, Huang LH, Chen JQ, Dai ZJ, Wang XM. A target-oriented algorithm for maintaining serum calcium stability automatically in regional citrate anticoagulation. Int J Artif Organs 2020; 44:551-559. [PMID: 33339480 DOI: 10.1177/0391398820982620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) for renal replacement therapy is widely practiced in critically ill patients. However, concern exists regarding its labor-intensiveness for monitoring and the associated hypocalcemia. In this study, we provided an algorithm for prescribing RCA and evaluated its safety in patients. METHODS During 18 hemofiltration treatments with calcium-free replacement solution, participants were randomized to receive algorithm-based or trial-and-error RCA protocol. The effluent volume, post-filter and in vivo ionized calcium (iCa), and calcium in the sera and effluents were periodically measured at an interval of 1 to 2 h. RESULTS For patients received algorithm-based RCA protocol, no one had a serum iCa less than 0.9 mmol/L, and none needed calcium supplement adjustment to maintain serum calcium stability. For patients accepted trial-and-error protocol, all patients had a serum iCa below 0.9 mmol/L, their serum iCa and calcium levels fluctuated dramatically, and all patients need additional calcium supplement adjustment during RCA. None of the participants showed a post-filter iCa > 0.4 mmol/L. CONCLUSION We provided a safe algorithm for calculating calcium supplementation doses that could maintain serum calcium stability without additional adjustment during RCA.
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Affiliation(s)
- Ruan-Mei Sheng
- Department of Emergency Medicine and Intensive Care, Shanghai Songjiang Clinical Medical College of Nanjing Medical University, Shanghai, China
| | - Wen-Biao Zhao
- Department of Emergency Medicine and Intensive Care, Shanghai Songjiang Clinical Medical College of Nanjing Medical University, Shanghai, China
| | - Li-Hong Huang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Qin Chen
- Department of Emergency Medicine and Intensive Care, Shanghai Songjiang Clinical Medical College of Nanjing Medical University, Shanghai, China
| | - Zhen-Juan Dai
- Department of Emergency Medicine and Intensive Care, Shanghai Songjiang Clinical Medical College of Nanjing Medical University, Shanghai, China
| | - Xue-Min Wang
- Department of Emergency Medicine and Intensive Care, Shanghai Songjiang Clinical Medical College of Nanjing Medical University, Shanghai, China
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34
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Giani M, Scaravilli V, Stefanini F, Valsecchi G, Rona R, Grasselli G, Bellani G, Pesenti AM, Foti G. Continuous Renal Replacement Therapy in Venovenous Extracorporeal Membrane Oxygenation: A Retrospective Study on Regional Citrate Anticoagulation. ASAIO J 2020; 66:332-338. [PMID: 31045918 DOI: 10.1097/mat.0000000000001003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Systemic infusion of unfractionated heparin (UFH) is the standard anticoagulation technique for continuous renal replacement therapy (CRRT) during extracorporeal membrane oxygenation (ECMO), but often fails to avoid CRRT circuit clotting. The aim of this study was to assess, in patients undergoing CRRT during venovenous ECMO (vv-ECMO), the efficacy and safety of adding regional citrate anticoagulation (RCA) for CRRT circuit anticoagulation (RCA + UFH group) compared with the sole systemic heparin anticoagulation (UFH group). We performed a retrospective chart review (2009-2018) of patients treated with CRRT during ECMO. We evaluated filter life span, rate of CRRT circuit clotting, and coagulation parameters. The incidence of citrate anticoagulation-related complications was recorded. Forty-eight consecutive adult patients underwent CRRT during vv-ECMO in the study period. The incidence of CRRT circuit clotting was lower in the RCA + UFH group (11% vs. 38% in the UFH group, p < 0.001). Log-rank survival analysis demonstrated longer circuit lifetime for RCA + UFH group. No complication ascribable to citrate anticoagulation was recorded. Regional citrate anticoagulation resulted a feasible, safe, and effective technique as additional anticoagulation for CRRT circuits during ECMO. Compared with systemic heparinization only, this technique allowed to reduce the rate of CRRT circuit clotting.
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Affiliation(s)
- Marco Giani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Flavia Stefanini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Gabriele Valsecchi
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Giacomo Grasselli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giacomo Bellani
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Antonio M Pesenti
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy
| | - Giuseppe Foti
- From the Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, ASST Monza, Monza, Italy.,Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy
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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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36
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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: 53] [Impact Index Per Article: 13.3] [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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37
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Anand AC, Nandi B, Acharya SK, Arora A, Babu S, Batra Y, Chawla YK, Chowdhury A, Chaoudhuri A, Eapen EC, Devarbhavi H, Dhiman RK, Datta Gupta S, Duseja A, Jothimani D, Kapoor D, Kar P, Khuroo MS, Kumar A, Madan K, Mallick B, Maiwall R, Mohan N, Nagral A, Nath P, Panigrahi SC, Pawar A, Philips CA, Prahraj D, Puri P, Rastogi A, Saraswat VA, Saigal S, Shalimar, Shukla A, Singh SP, Verghese T, Wadhawan M. Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure. J Clin Exp Hepatol 2020; 10:477-517. [PMID: 33029057 PMCID: PMC7527855 DOI: 10.1016/j.jceh.2020.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/12/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.
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Key Words
- ACLF, Acute on Chronic liver Failure
- AKI, Acute kidney injury
- ALF, Acute Liver Failure
- ALFED score
- ALT, alanine transaminase
- AST, aspartate transaminase
- CNS, central nervous system
- CT, Computerized tomography
- HELLP, Hemolysis, elevated liver enzymes, and low platelets
- ICH, Intracrainial hypertension
- ICP, Intracrainial Pressure
- ICU, Intensive care unit
- INR, International normalised ratio
- LAD, Liver assist device
- LDLT, Living donor liver transplantation
- LT, Liver transplantation
- MAP, Mean arterial pressure
- MELD, model for end-stage liver disease
- MLD, Metabolic liver disease
- NAC, N-acetyl cysteine
- PALF, Pediatric ALF
- WD, Wilson's Disease
- acute liver failure
- artificial liver support
- liver transplantation
- plasmapheresis
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Affiliation(s)
- Anil C. Anand
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Bhaskar Nandi
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sethu Babu
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
| | - Yogesh Batra
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
| | - Ashok Chaoudhuri
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Eapen C. Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
| | | | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Mohamad S. Khuroo
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kaushal Madan
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
| | - Bipadabhanjan Mallick
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Rakhi Maiwall
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Aabha Nagral
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Preetam Nath
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Sarat C. Panigrahi
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Ankush Pawar
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
| | - Cyriac A. Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
| | - Dibyalochan Prahraj
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Pankaj Puri
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
| | - Amit Rastogi
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Sanjiv Saigal
- Department of Hepatology, Department of Liver Transplantation, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
| | - Akash Shukla
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Thomas Verghese
- Department of Gastroenterology, Government Medical College, Kozikhode, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
| | - The INASL Task-Force on Acute Liver Failure
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Hepatology, Christian Medical College, Vellore, India
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
- Gleneagles Global Hospitals, Hyderabad, Telangana, India
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
- Department of Hepatology, Department of Liver Transplantation, India
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
- Department of Gastroenterology, Government Medical College, Kozikhode, India
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
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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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Donati G, Angeletti A, Gasperoni L, Piscaglia F, Croci Chiocchini AL, Scrivo A, Natali T, Ullo I, Guglielmo C, Simoni P, Mancini R, Bolondi L, La Manna G. Detoxification of bilirubin and bile acids with intermittent coupled plasmafiltration and adsorption in liver failure (HERCOLE study). J Nephrol 2020; 34:77-88. [PMID: 32710265 PMCID: PMC7881965 DOI: 10.1007/s40620-020-00799-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/04/2020] [Indexed: 01/15/2023]
Abstract
Background CPFA is an extracorporeal treatment used in severe sepsis to remove circulating proinflammatory cytokines. Limited evidence exists on the effectiveness of bilirubin adsorption by the hydrophobic styrenic resin, the distinctive part of CPFA. The aim of this study is to validate CPFA effectiveness in liver detoxification. Methods In this prospective observational study, we enrolled patients with acute or acute-on-chronic liver failure (serum total bilirubin > 20 mg/dL or MELD Score > 20) hospitalized from June 2013 to November 2017. CPFA was performed using the Lynda (Bellco/MedTronic, Mirandola, Italy) or the Amplya (Bellco/MedTronic, Mirandola, Italy) machines. Anticoagulation was provided with unfractionated heparin or citrate. Bilirubin and bile acids reduction ratios per session (RRs) were the main parameters for hepatic detoxification. Results Twelve patients with acute (n = 3) or acute-on-chronic (n = 9) liver failure were enrolled. Alcohol was the main cause of liver disease. Thirty-one CPFA treatments of 6 h each were performed, 19 with heparin and 12 with citrate. RRs was 28.8% (range 2.2–40.5) for total bilirubin, 32.7% (range 8.3–48.9) for direct bilirubin, 29.5% (range 6.5–65.4) for indirect bilirubin and 28.9% (16.7- 59.7) for bile acids. One patient received liver transplantation and 8/9 were alive at 1 year of follow-up. Three patients (25%) died: 2 during hospitalization and 1 for a cardiac event at 4 months of follow up with restored liver function. Conclusions CPFA resulted to be effective in liver detoxification. Thus, it may be considered as a “bridge technique” both to the liver transplant and to the recovery of the basal liver function.
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Affiliation(s)
- Gabriele Donati
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Andrea Angeletti
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Fabio Piscaglia
- Internal Medicine Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Anna Laura Croci Chiocchini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Anna Scrivo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Teresa Natali
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Ines Ullo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Chiara Guglielmo
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy
| | - Patrizia Simoni
- Laboratory of Gastroenterology, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Rita Mancini
- Metropolitan Laboratory, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luigi Bolondi
- Internal Medicine Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplantation Unit, S. Orsola Hospital, University of Bologna, Via G. Massarenti 9 (Pad. 15), 40138, Bologna, Italy.
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Honore PM, Rimmelé T. Total-to-ionized calcium ratio, taken alone, is no longer valid to diagnose citrate accumulation! What additional parameters should we consider to strengthen the utility of this ratio? J Crit Care 2020; 59:172-175. [PMID: 32679468 DOI: 10.1016/j.jcrc.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick M Honore
- Professor of Medicine, ICU Department, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Thomas Rimmelé
- Professor of Medicine, Head of Anesthesiology and Criticial Care Medicine Department, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.
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Boer W, van Tornout M, Solmi F, Willaert X, Schetz M, Oudemans-van Straaten H. Determinants of Total/ionized Calcium in patients undergoing citrate CVVH: A retrospective observational study. J Crit Care 2020; 59:16-22. [PMID: 32485438 DOI: 10.1016/j.jcrc.2020.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/11/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To identify potential determinants of the Total/ionized Ca ratio (T/iCa), a marker of citrate accumulation. MATERIALS AND METHODS Single-center retrospective observational study evaluating citrate dose, citrate target, albumin, phosphate, pH, lactate, and APACHE II score as potential determinants. Linear mixed models (LMM) using citrate dose and citrate target were developed describing associations with T/iCa. RESULTS From a dataset of 471 samples in 103 patients, an LMM in 379 complete samples (95 patients) sets revealed that citrate dose, pH, phosphate, albumin and APACHE were interactively related to T/iCa. A rising citrate dose was associated with a higher increase in T/iCa when phosphate was high, and less when phosphate was low. A rising albumin was associated with a higher increase in T/iCa when APACHE was high and phosphate was low and less when APACHE was low and phosphate high. In case of acidosis, a rising lactate was associated with a higher increase in T/iCa. In the LMM using citrate target, citrate target and pH were the main independent predictors of T/iCa with albumin, phosphate and APACHE score as modifiers. CONCLUSIONS Besides citrate dose, a high pH and high phosphate, albumin and APACHE are also associated with a rising T/iCa.
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Affiliation(s)
- Willem Boer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Mathias van Tornout
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Francesca Solmi
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Hasselt, Belgium
| | - Xavier Willaert
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Miet Schetz
- Department of Laboratory and Intensive Care Medicine, Catholic University Leuven, Belgium
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Yu Y, Bai M, Ma F, Zhang W, Li Y, Zhao L, Li L, Zhou M, Li L, Sun S. Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study. PLoS One 2020; 15:e0232516. [PMID: 32369523 PMCID: PMC7199954 DOI: 10.1371/journal.pone.0232516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 04/16/2020] [Indexed: 01/01/2023] Open
Abstract
Objective There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients. Methods The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes. Results In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2–47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26–0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups. Conclusions In LF patients with increased bleeding risk who underwent CVVH, RCA could prolong the filter lifespan and be safely used with careful blood gas monitoring and citrate dose adjusting. Further prospective, randomized, control studies are warranted to obtain robust evidences.
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Affiliation(s)
- Yan Yu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Wei Zhang
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Li Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Meilan Zhou
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Shaanxi, China
- * E-mail: (MB); (SS)
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Dialysis modalities for the management of pediatric acute kidney injury. Pediatr Nephrol 2020; 35:753-765. [PMID: 30887109 DOI: 10.1007/s00467-019-04213-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/19/2019] [Accepted: 02/08/2019] [Indexed: 01/11/2023]
Abstract
Acute kidney injury (AKI) is an increasingly frequent complication among hospitalized children. It is associated with high morbidity and mortality, especially in neonates and children requiring dialysis. The different renal replacement therapy (RRT) options for AKI have expanded from peritoneal dialysis (PD) and intermittent hemodialysis (HD) to continuous RRT (CRRT) and hybrid modalities. Recent advances in the provision of RRT in children allow a higher standard of care for increasingly ill and young patients. In the absence of evidence indicating better survival with any dialysis method, the most appropriate dialysis choice for children with AKI is based on the patient's characteristics, on dialytic modality performance, and on the institutional resources and local practice. In this review, the available dialysis modalities for pediatric AKI will be discussed, focusing on indications, advantages, and limitations of each of them.
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Khadzhynov D, Deissler J, Bobonov O, Schelter C, Peters H, Kindgen-Milles D, Budde K, Lehner LJ, Halleck F, Staeck O, Eckardt KU, Slowinski T. Intensive monitoring of post filter ionized calcium concentrations during CVVHD with regional citrate anticoagulation: A retrospective study. J Crit Care 2020; 58:1-5. [PMID: 32244094 DOI: 10.1016/j.jcrc.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of the present study was to assess the predictive value of post-filter ionized calcium (pfCa) levels for filter-clotting during continuous veno-venous hemodialysis (CVVHD) with regional citrate anticoagulation (RCA). METHODS Retrospective analysis of a database derived from 6 intensive care units (ICU) at a university hospital. During the 3-year period 1070 patients were treated with RCA-CVVHD with a citrate starting dose of 4 mmol/L blood and a target-range for pfCa of 0.25-0.35 mmol/L. RESULTS The pfCa concentrations at RCA-CVVHD initiation were within the target range in 69.7% of patients. Within 12 h the fraction of patients with pfCa above target-range decreased significantly from 13.1% to 7.8% (p < .001). There was no significant difference in filter survival between patients with a pfCa initially below, within, or above the target-range (83.7%, 89.5% and 90.4%; p = .228) and no significant correlation between the last pfCa and the incidence of filter clotting (rho 0.018, p = .572 and -0.054, p = .104; respectively). CONCLUSIONS CVVHD with a citrate starting dose of 4 mmol/L blood resulted in a pfCa within target in the majority of patients. The observation that pfCa was not associated with the incidence of circuit clotting suggests that less frequent measurements of pfCA might be safe.
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Affiliation(s)
- Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Jonas Deissler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Otajon Bobonov
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Christin Schelter
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Harm Peters
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine-University, Germany.
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Oliver Staeck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
| | - Torsten Slowinski
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Charitéplatz 1, 10117 Berlin, Germany.
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Honore PM, Mugisha A, David C, Attou R, Redant S, Gallerani A, De Bels D. In severe liver disease, citrate can be used safely: the question remains-by which mechanism. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:63. [PMID: 32093726 PMCID: PMC7038605 DOI: 10.1186/s13054-020-2801-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Aurore Mugisha
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Cristina David
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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Abstract
PURPOSE OF REVIEW The delivery of an effective dialysis dose in continuous renal replacement therapy (CRRT) depends on adequate anticoagulation of the extracorporeal circuit. In most patients, either systemic heparin anticoagulation (SHA) or regional citrate anticoagulation (RCA) is used. This review will outline the basics and rationale of RCA and summarize data on safety and efficacy of both techniques. RECENT FINDINGS The basic principle of RCA is to reduce the level of ionized calcium in the extracorporeal circuit via infusion of citrate. This way, effective anticoagulation restricted to the extracorporeal circuit is achieved. SHA and RCA were compared in a variety of studies. RCA significantly prolonged filter lifetime, reduced bleeding complications and provided excellent control of uremia and acid-base status. RCA was also safe in the majority of patients with impaired liver function, whereas caution must be exerted in those with severe multiorgan failure and persistent hyperlactatemia. SUMMARY RCA per se is safe and effective for anticoagulation of CRRT. Compared to SHA, efficacy of anticoagulation is improved and adverse effects are reduced. RCA can be recommended as the anticoagulation mode of choice for CRRT in most ICU patients.
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Francey T, Schweighauser A. Membrane-based therapeutic plasma exchange in dogs: Prescription, anticoagulation, and metabolic response. J Vet Intern Med 2019; 33:1635-1645. [PMID: 31115107 PMCID: PMC6639492 DOI: 10.1111/jvim.15528] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 05/09/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is used increasingly in small animals to remove circulating large molecular products such as antibodies, pathogenic proteins, and protein-bound toxins. Specific, efficient, and safe protocols need to be developed. HYPOTHESIS/OBJECTIVES To describe the technique of membrane-based TPE, the resulting physiological and metabolic changes, and to define an adequate regional citrate anticoagulation protocol. ANIMALS Thirty-four dogs treated with TPE (2011-2017). METHODS Retrospective review of all TPE treatments performed at the Vetsuisse Faculty, University of Bern, identified through a search of the institutional database for extracorporeal treatments. RESULTS Sixty-four treatments were performed, resulting in 1.0 plasma volume exchange (range, 0.4-1.1). Replacement fluids included fresh frozen plasma (12%-100% volume), colloids (0%-52%), human albumin (0%-41%), and saline (0%-70%). Anticoagulation was performed with regional citrate (n = 24), systemic heparinization (n = 2), or combined (n = 38). Main relevant laboratory changes included a 24.7% decrease in total proteins (interquartile range, 16.7-31.4; P < .001), 53% in fibrinogen (-30 to 63; P = .009), 36% in bilirubin (13-43, P = .02), 9.0% in urea (0.7-15.7; P < .001), and 4.5% in creatinine (-6.6 to 10.6; P = .006). Citrate accumulation was evidenced in all dogs, more pronounced in those with renal but not with hepatic impairment. Maximal tolerable citrate rates were estimated as 5.5 and 9.0 μmol/kg/min for treatments in dogs with and without renal impairment, respectively. Complications were observed in 22 treatments (34%) and were fatal in 2 dogs. CONCLUSIONS AND CLINICAL IMPORTANCE Therapeutic plasma exchange causes metabolic and biochemical alterations. Understanding these effects makes possible to anticipate most complications and to improve safety of the procedure.
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Affiliation(s)
- Thierry Francey
- Division of Small Animal Internal Medicine, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ariane Schweighauser
- Division of Small Animal Internal Medicine, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Inducible metabolic pathway for citrate metabolism in case of major liver dysfunction: fact or fiction? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:166. [PMID: 31088498 PMCID: PMC6515620 DOI: 10.1186/s13054-019-2432-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/10/2019] [Indexed: 11/10/2022]
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Gao J, Wang F, Wang Y, Jin D, Tang L, Pan K. A mode of CVVH with regional citrate anticoagulation compared to no anticoagulation for acute kidney injury patients at high risk of bleeding. Sci Rep 2019; 9:6607. [PMID: 31036927 PMCID: PMC6488647 DOI: 10.1038/s41598-019-42916-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 04/10/2019] [Indexed: 12/21/2022] Open
Abstract
The study was designed to assess a practical mode of postdilution continuous venovenous hemofiltration (CVVH) with regional citrate anticoagulation (RCA) using a calcium-containing replacement solution, and to compare it with a CVVH mode with no anticoagulation (NA). Both methods were employed in our center for acute kidney injury (AKI) patients at high risk of bleeding. Fifty-six patients were equally allocated into the RCA-CVVH group and the NA-CVVH group. The study displayed no significant differences between groups involving baseline characteristics, severity level, blood gas analysis, hepatic/renal/coagulative functions, electrolytes, hemoglobin concentration, and platelet counts before or after continuous renal replacement therapy (CRRT). Compared to the NA-CVVH group, the RCA-CVVH group had a lower level of transfused packed red blood cells and platelet as well as a longer filter lifespan. The result showed no substantial differences between groups in terms of the mean supporting time and cost involving CRRT per person, the length of ICU and hospital stays, and the ICU survival. Homeostasis was basically preserved at a target range during the RCA post-CVVH procedure. Serious complications did not arise during the RCA process. RCA postdilutional CVVH is a safe and effective mode for application in AKI patients with a high risk of bleeding, and it can extend the filter lifespan and decrease blood loss, compared with the NA mode for CRRT. Further studies are needed to evaluate this mode for CRRT. (Retrospective Registration number ChiCTR1800016462, Registration date 2/6/2018)
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Affiliation(s)
- Jianping Gao
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Feng Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Yonggang Wang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Dan Jin
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Liping Tang
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Konghan Pan
- Critical Care Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
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Borisov AS, Malov AA, Kolesnikov SV, Lomivorotov VV. Renal Replacement Therapy in Adult Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2273-2286. [PMID: 30871949 DOI: 10.1053/j.jvca.2019.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Alexander S Borisov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Andrey A Malov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Sergey V Kolesnikov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anaesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia.
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