Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge

Abstract

RCA may be a safe and useful form of anticoagulation which is more expensive than heparinization but helps to minimize bleeding risk. The risk of metabolic complications is higher at the beginning of a new RCA program. For centers lacking experienced staff we suggest reserving this technique for patients with rapid clotting of the extracorporeal circuit if treated without anticoagulation.

A Practical Citrate Anticoagulation Continuous Venovenous Hemodiafiltration Protocol for Metabolic Control and High Solute Clearance

“…In addition, the ultrafiltration rate was limited to 2 L/h, as a result of the risk for citrate toxicity. Gabutti et al (6) evaluated 12 patients using dilute citrate as both replacement fluid and dialysate. In their approach, the compositions of the dialysate and/or replacement fluid were titrated on the basis of systemic pH.…”

“…A small number of regional citrate anticoagulation protocols offer high solute clearance but also require several customized solutions (5)(6)(7)(8)(9)(10). Customization of solutions, with subsequent adjustments based on or determined by patient clinical status, expends pharmacy resources and increases the risk for error (11).…”

The Acid-Base Effect of Changing Citrate Solution for Regional Anticoagulation during Continuous Veno-Venous Hemofiltration

“…Regional citrate anticoagulation (RCA) has been used for continuous renal replacement therapy (CR-RT) in patients at high risk of bleeding for more than 15 years (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). In RCA-CRRT, there are 3 major forms of citrate administration.…”

“…In RCA-CRRT, there are 3 major forms of citrate administration. One is 4% trisodium citrate (2,3,5,6,8,16,17), another is acid citrate dextrose solution (ACD) (11)(12)(13)(14)(15) and a third is citrate containing replacement fluid (4,7,9,10). Recently, a commercial citrate-containing replacement solution was developed for RCA during continuous veno-venous hemofiltration (CVVH) in Australia according to the principles described by Palsson et al (4) and Dorval et al (9) with modification toward a lower citrate concentration (Citrate A; citrate=11mmol/L) (18,19).…”

Is there a real alternative anticoagulant to heparin in continuous treatments?

“…When heparin is used intravenously as an anticoagulant for maintaining extracorporeal circuit patency during CRRT, the incidence of bleeding episodes, considering all of the administration methods, ranges from 10 to 50%, with mortality due to bleeding as high as 15% [3][4][5]. Heparin is clearly contraindicated in patients with active bleeding or at high risk of bleeding, as it is often seen in patients with extensive open surfaces as a result of trauma, burns or surgery [3].…”