Detection of citrate overdose in critically ill patients on citrate-anticoagulated venovenous haemofiltration: use of ionised and total/ionised calcium

Bakker, A.; Boerma, E. Christiaan; Keidel, Halbe; Kingma, Peter; Voort, Peter H. J. van der

doi:10.1515/cclm.2006.164

Cited by 76 publications

(73 citation statements)

References 20 publications

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“…The accumulation degree of citrates was measured by tCa/iCa ratio. According to its cut-off value 2.1, all cases were divided into two groups as the low citrate group (tCa/iCa ratio <2.1) and the high citrate group (tCa/ iCa ratio ≥2.1) [25]. Outcome was all-cause death.…”

Section: Data Categorizationmentioning

confidence: 99%

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Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Yu¹,

Peng²,

Cen³

et al. 2018

Kidney Blood Press Res

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Background/Aims: Continuous renal replacement therapy (CRRT) is a treatment for acute kidney injury (AKI) patients. It has become a controversy about whether patients with liver dysfunction should perform CRRT with regional citrate anticoagulation (RCA). Methods: This retrospective observational study enrolled 145 AKI patients (275 CRRT sessions) who received CRRT with RCA and had no history of chronic liver disease. Circuit survival time, blood pressure, trans-membrane pressure (TMP), acid-base and electrolyte status were recorded and analyzed. The severity of liver dysfunction was determined by total bilirubin (TBil) and international normalized ratio (INR), while the accumulation degree of citrates was quantified by total/ ionized calcium (tCa/iCa) raito. Results: Our results showed that there was no correlation of tCa/iCa ratio with TBil or INR. And tCa/iCa ratio was not related to the disturbances of pH, lactates, sodium, magnesium, blood pressure or TMP despite that high tCa/iCa ratios might be related to the decrease of circuit survival time. TBil did not correlate with the above indexes, except for lactates levels. INR did not correlate with the above indexes except for lactates levels and blood pressure. In addition, neither was TBil, INR, nor tCa/iCa ratio, related with fatal outcomes (22.76% of the patients). Conclusion: The present study demonstrated that, with proper monitoring and adjustment of citrates and calcium infusion, applying RCA in CRRT is reasonably safe for AKI patients with acute liver dysfunction, as long as circuit time stays below roughly 50 hours.

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Section: Data Categorizationmentioning

confidence: 99%

“…Using tCa/iCa ratio of 2.1 as the threshold [25], all cases were categorized into two groups. Different variables recorded in the end of CRRT were compared between these two groups ( Table 2).…”

Section: Comparing Different Variables In the End Of Crrt Between Thementioning

confidence: 99%

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Yu¹,

Peng²,

Cen³

et al. 2018

Kidney Blood Press Res

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“…As a consequence, progressively higher calcium infusion rates may be required to maintain the ionized calcium concentration within physiologic limits, and there may be a disproportionate rise in both the total systemic calcium concentration and the total-to-ionized calcium ratio (the calcium ratio) (11,22,44,52). In clinical practice, because the calcium ratio is related to the blood citrate concentration, it is commonly accepted as an indirect index of citrate accumulation during RCA (45,48,(53)(54)(55). A calcium ratio.2.5 is considered the critical threshold for increased risk of metabolic complications caused by impaired citrate metabolism (54).…”

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

confidence: 99%

“…A calcium ratio.2.5 is considered the critical threshold for increased risk of metabolic complications caused by impaired citrate metabolism (54). However, it has been reported that a lower cutoff of 2.1 seems to accurately predict citrate overdose (systemic citrate concentration.1 mmol/L) with high sensitivity and specificity (89% and 100%, respectively) (55). It should be recognized that the suggested cutoff values for the calcium ratio were obtained without any adjustment of total systemic calcium for serum albumin.…”

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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“…The totalto-ionised calcium ratio is, therefore, an important marker to detect citrate accumulation. 23,24 An Abbreviations: C = regional citrate group; H = heparin group; LMWH = low-molecular-weight heparin; NR = not reported; UFH = unfractionated heparin * Mean age † Median age elevated ratio of >2.25 should alert the clinician to the possibility of citrate accumulation. Impaired citrate metabolism is an independent risk factor for mortality.…”

Section: Citrate Toxicitymentioning

confidence: 99%

Risks and benefits of citrate anticoagulation for continuous renal replacement therapy

Shum¹,

Wu²,

Chan³

2014

Hong Kong Med J

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A B S T R A C THeparin, despite its significant side-effects, is the most commonly used anticoagulant for continuous renal replacement therapy in critical care setting. In recent years, citrate has gained much popularity by improving continuous renal replacement therapy circuit survival and decreasing blood transfusion requirements. However, its complex metabolic consequences warrant modification in the design of the citrate-based continuous renal replacement therapy protocol. With thorough understanding of the therapeutic mechanism of citrate, a simple and practicable protocol can be devised. Citratebased continuous renal replacement therapy can

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Detection of citrate overdose in critically ill patients on citrate-anticoagulated venovenous haemofiltration: use of ionised and total/ionised calcium

Abstract: In patients without liver insufficiency, total/ionised calcium performed slightly better than ionised calcium in detecting elevated citrate concentrations. However, because of the simplicity of its measurement, ionised calcium is preferred. Measurement of citrate is not necessary.

Cited by 76 publications

References 20 publications

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Risks and benefits of citrate anticoagulation for continuous renal replacement therapy

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