Blood and ultrafiltrate dosage of citrate as a useful and routine tool during continuous venovenous haemodiafiltration in septic shock patients

Mariano, Filippo; Morselli, Maurizio; Bergamo, Daniela; Holló, Zsuzsanna; Scella, Sandro; Maio, Mariella; Tetta, Ciro; Dellavalle, Ambrogio; Stella, Maurizio; Triolo, G

doi:10.1093/ndt/gfr106

Cited by 52 publications

(66 citation statements)

References 25 publications

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“…It should be noted that the metabolic capacity of critically ill patients is often impaired in patients with severe lactic acidosis due to multiple organ failure [11] , liver or kidney dysfunction [12] , loss of muscle mass, and hypoxia [13] . To reduce the amount of citrate load that returned to the patient, continuous veno-venous hemodiafiltration was usually used to increase the clearance of citrate (as high as 40-60%) in the extracorporeal circuit by dialysate [14,15] . Other complications, such as hypernatremia and alkalosis, are also frequent in RCA, with a reported incidence of 5.5-23% [16] , since citrate infusion is essentially accompanied by extra-infusion of sodium and base.…”

Section: Discussionmentioning

confidence: 99%

Randomized Controlled Trial to Evaluate Regional Citrate Anticoagulation Plus Low-Dose of Dalteparin in Continuous Veno-Venous Hemofiltration

Zhang

et al. 2015

Blood Purif

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Background/Aims: To evaluate the efficacy and safety of regional citrate anticoagulation (RCA) plus low-dose dalteparin in patients receiving continuous veno-venous hemofiltration (CVVH). Methods: Patients requiring pre-dilution CVVH at 4 l/h were randomly assigned to group A (RCA only), group B (normal-dose dalteparin anticoagulation only) or group C (RCA plus low-dose dalteparin). The primary endpoint was filter runtime and the secondary endpoints were premature clotting of the filter and anticoagulation-related side effects. Results: Fifty-three patients completed the study. The mean filter runtime was significantly longer in group C (40.4 ± 30.9 h) than those in group A (21.2 ± 13.5 h, p = 0.006) and group B (25.1 ± 24.0 h, p = 0.040). The rate of premature clotting, new onset of bleeding, hypocalcemia and metabolic acidosis did not differ significantly in three groups. Conclusions: RCA plus low-dose dalteparin prolonged filter runtime compared with RCA only or normal-dose dalteparin only without increasing the incidence of anticoagulation-related complications.

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Section: Discussionmentioning

confidence: 99%

Randomized Controlled Trial to Evaluate Regional Citrate Anticoagulation Plus Low-Dose of Dalteparin in Continuous Veno-Venous Hemofiltration

Zhang

et al. 2015

Blood Purif

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“…In this regard, it is likely that SLED with nearautomated regional citrate anticoagulation protocols optimized for very low blood flows and low citrate loads (46), as well as the availability of routine citrate measurements (47), could represent important developments, in order to improve the safety and efficacy of the citrate-based "hybrid" extracorporeal modalities.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Fiaccadori¹,

Regolisti²,

Cademartiri³

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.Design, setting, participants, & measurements All patients treated with SLED (8-to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.Results This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (, 3.6 mg/dl or , 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).Conclusions This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.

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“…The citrate infusion rate is titrated to maintain low ionized calcium levels in the extracorporeal circuit that are sufficient to achieve full blood anticoagulation (i.e., 0.3-0.4 mmol/L) (11,22); this target is generally attained with a citrate level in the extracorporeal circuit of approximately 3 mmol/L (Figure 1) (32). Because both citrate anion and trisodium citrate complexes have low molecular weight (198 and 258, respectively), high sieving coefficients (0.85-1), and high diffusive/convective clearances, a significant quantity of the citrate anions and calcium-citrate complexes is lost in the effluent fluid (33,34). As a result, calcium infusion is usually needed to replace calcium losses and maintain systemic ionized calcium levels within the normal range ( Figure 1).…”

Section: Rca: Basic Principles and Citrate Metabolismmentioning

confidence: 99%

“…The suitability of the calcium ratio as a surrogate for blood citrate accumulation has only been partially confirmed (34,40). However, the measurement of blood or plasma citrate concentration is not widely available and generally cannot be obtained in a timely manner for rapid bedside clinical decision making.…”

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

confidence: 99%

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

127

130

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Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

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Blood and ultrafiltrate dosage of citrate as a useful and routine tool during continuous venovenous haemodiafiltration in septic shock patients

Abstract: In septic shock patients with liver dysfunction citratemia is useful in guiding clinical application of RRT, where the citrate losses in the ultrafiltrate can be efficiently modulated by increasing the effluent volume.

Cited by 52 publications

References 25 publications

Randomized Controlled Trial to Evaluate Regional Citrate Anticoagulation Plus Low-Dose of Dalteparin in Continuous Veno-Venous Hemofiltration

Randomized Controlled Trial to Evaluate Regional Citrate Anticoagulation Plus Low-Dose of Dalteparin in Continuous Veno-Venous Hemofiltration

Efficacy and Safety of a Citrate-Based Protocol for Sustained Low-Efficiency Dialysis in AKI Using Standard Dialysis Equipment

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

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