Continuous Veno-Venous Hemofiltration using a Phosphate-Containing Replacement Fluid in the Setting of Regional Citrate Anticoagulation

Morabito, Santo; Pistolesi, Valentina; Tritapepe, Luigi; Vitaliano, E; Zeppilli, Laura; Polistena, Francesca; Fiaccadori, Enrico; Pierucci, Alessandro

doi:10.5301/ijao.5000283

Cited by 26 publications

(18 citation statements)

References 24 publications

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“…Heparin, heparin-protamine regional anticoagulation and no-AC CRRT were performed in predilution continuous venovenous hemodiafiltration (CVVHDF) using a bicarbonate solution (Prismasol 2, Gambro, Sondalo, Italy) as dialysate and replacement fluid in a proportion of 60 % and 40 % of total CRRT dose, respectively. RCA-CRRT was performed using a low concentration citrate solution (12 mmol/l Prismocitrate 10/2 or 18 mmol/l Prismocitrate 18/0, Gambro, Sondalo, Italy) combined with a bicarbonate-buffered CRRT solution (Prismasol 2 or Phoxilium, Gambro, Sondalo, Italy) according to protocols described elsewhere [20][21][22].…”

Section: Methodsmentioning

confidence: 99%

Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT)

Pistolesi

Napoli²,

Fiaccadori

et al. 2015

J Nephrol

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In a selected population of patients with severe CS-AKI requiring RRT, short-term outcomes appear strongly associated with the worst grade of illness severity during the first week of CRRT, thus reflecting the sequential occurrence of additional major complications during ICU stay. Renal function recovery and in-hospital survival appear mutually linked, sharing oliguria, sepsis and SOFA score as the main determinants of both outcomes.

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Section: Methodsmentioning

confidence: 99%

Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT)

Pistolesi

Napoli²,

Fiaccadori

et al. 2015

J Nephrol

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“…This approach enabled the prevention of hypophosphatemia, in addition to avoiding the need for phosphate supplementation [17] . The protocol was further refined and successfully tested in 2 small case series in RCA-CVVH and RCA-CVVHDF modalities [18,19] . The RCA-CVVHDF modality is now routinely adopted at our Institution; in this study conducted in 75 CS-AKI patients undergoing prolonged CRRT periods, we report the main findings derived from 4 years of its extended use.…”

Section: Discussionmentioning

confidence: 99%

Preventing Continuous Renal Replacement Therapy-Induced Hypophosphatemia: An Extended Clinical Experience with a Phosphate-Containing Solution in the Setting of Regional Citrate Anticoagulation

Pistolesi¹,

Zeppilli²,

Polistena³

et al. 2017

Blood Purif

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Aims: To evaluate the efficacy and safety of a commercially available phosphate-containing solution for continuous renal replacement therapy (CRRT) in preventing CRRT-related hypophosphatemia. Methods: In heart surgery patients undergoing continuous veno-venous haemodiafiltration (CVVHDF) with regional citrate anticoagulation (RCA), we combined an 18 mmol/l citrate solution with a phosphate-containing (1.2 mmol/l) dialysate/replacement fluid evaluating the incidence of hypophosphatemia and the need for parenteral phosphorus supplementation. Results: In 75 patients on RCA-CVVHDF, the mean filter life was 53.9 ± 33.6 h. Regardless of baseline levels, phosphoremia was progressively corrected and maintained in a narrow normality range throughout RCA-CRRT days (after 72 h: 1.14 ± 0.25 mmol/l). Considering the whole CRRT period, 45 out of 975 (4.6%) serum phosphorus determinations met the criteria for mild (<0.81 mmol/l) or moderate (<0.61 mmol/l) hypophosphatemia; severe hypophosphatemia (<0.32 mmol/l) never occurred. After 72 h 88% of the patients were normophosphatemic, 9% hyperphosphatemic and 3% hypophosphatemic. Conclusions: RCA-CVVHDF with a phosphate-containing solution enabled the maintenance of phosphorus levels within normophosphatemic range in most of the patients, minimizing the occurrence of CRRT-related hypophosphatemia.

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“…The physiologic sodium content of isotonic solutions allows RCA CVVH or RCA CVVHDF without the need of a low-sodium replacement fluid and/ or dialysate (Table 1). In protocols using citrate-buffered replacement solutions, the buffer supply derives from citrate (predilution CVVH) or citrate and bicarbonate in various proportions (predilution and postdilution CVVH and CVVHDF) in relation to the composition and the combination of the solutions that are used (14,19,50,62,(64)(65)(66)(67). A simplification on the basis of the use of solutions with an appropriately low citrate concentration allows RCA CRRT as CVVH in the predilution-only modality (19,50).…”

Section: Low-concentration Citrate Solutions (Isotonic In Sodium)mentioning

confidence: 99%

“…For example, the adoption of RCA protocols in which predilution citrate is combined with a calcium-containing dialysate and/or replacement fluid may reduce the calcium infusion requirements and minimize the risks of errors related to the handling of calcium-free solutions (14,51,66,67,103). These protocols seem to be able to provide prolonged filter survival without any increase in venous drip chamber clotting rates or the need to increase the initial citrate dose (14,66,67). However, in any protocol, variations in operational parameters and calcium concentration in the CRRT solutions could significantly affect the need for citrate dose adjustments.…”

Section: Rca Protocols Simplification: Future Perspectivesmentioning

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

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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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Continuous Veno-Venous Hemofiltration using a Phosphate-Containing Replacement Fluid in the Setting of Regional Citrate Anticoagulation

Cited by 26 publications

References 24 publications

Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT)

Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT)

Preventing Continuous Renal Replacement Therapy-Induced Hypophosphatemia: An Extended Clinical Experience with a Phosphate-Containing Solution in the Setting of Regional Citrate Anticoagulation

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

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