Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy

Warnar, C; Faber, E; Katinakis, P. A.; Schermer, Tjard; Spronk, Peter E.

doi:10.1007/s10877-021-00719-8

Cited by 4 publications

(2 citation statements)

References 33 publications

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“…Second, no direct measurement of citrate plasma concentration was performed. However, its accumulation was monitored according to current guidelines [35].…”

Section: Limitationsmentioning

confidence: 99%

Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review

Brunoni,

Zadek,

Mulazzani

et al. 2023

Blood Purif

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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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“…Second, no direct measurement of citrate plasma concentration was performed. However, its accumulation was monitored according to current guidelines [35].…”

Section: Limitationsmentioning

confidence: 99%

Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review

Brunoni,

Zadek,

Mulazzani

et al. 2023

Blood Purif

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“…Moreover, because citrate is degraded promptly and bound calcium is released when citrate administration is terminated 3 , 7 , inappropriate calcium supplementation can potentially cause a rapid rise in serum iCa after leukapheresis. Indeed, serious hypercalcemia associated with citrate anticoagulation has been reported in renal replacement therapy and apheresis 8 – 10 , and a healthy donor with transient impaired consciousness due to hypercalcemia after PBSC collection has been reported 11 . Therefore, it is essential to address fluctuation of serum iCa not only during leukapheresis, but also thereafter, in order to optimize calcium supplementation methods.…”

Section: Introductionmentioning

confidence: 99%

Risk analysis of fluctuating hypercalcemia after leukapheresis in cellular therapy

Jo,

Arai,

Kitawaki

et al. 2023

Sci Rep

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Optimized management of citrate-induced hypocalcemia is required to provide safe leukapheresis. We prospectively analyzed subjects who underwent leukapheresis for cytotherapy, and evaluated serum ionized (iCa) concentrations before, at the end of, and 1 h after leukapheresis. During leukapheresis, calcium gluconate solution was continuously supplemented intravenously with hourly measurement of iCa. 76 patients including 49 lymphapheresis for chimeric antigen receptor T-cell therapy and 27 stem cell collections were enrolled. Median processing blood volume was 10 L (range, 6–15 L). Fluctuating hypercalcemia, in which the iCa concentration rose above its upper limit 1 h after leukapheresis, was observed in 58 subjects (76.3%). Multivariate analysis revealed that higher ratios of processing blood volume to body weight, more rapid calcium supplementation, and lower iCa concentration at the end of leukapheresis significantly increased elevation of serum iCa concentration by 1 h after leukapheresis. Based on multivariate analyses, we developed a formula and a diagram that accurately estimates serum iCa concentration 1 h post-leukapheresis. This suggests optimal targets for iCa concentration and calcium supplementation rates. In cases with high ratios of processing blood volume to body weight, slowing the rate of blood processing, rather than increasing calcium supplementation should safely alleviate hypocalcemia during leukapheresis without inducing hypercalcemia thereafter.

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Construction and evaluation of a mortality prediction model for patients with acute kidney injury undergoing continuous renal replacement therapy based on machine learning algorithms

Wang,

Sun,

et al. 2024

Annals of Medicine

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Background To construct and evaluate a predictive model for in-hospital mortality among critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT), based on nine machine learning (ML) algorithm. Methods The study retrospectively included patients with AKI who underwent CRRT during their initial hospitalization in the United States using the medical information mart for intensive care (MIMIC) database IV (version 2.0), as well as in the intensive care unit (ICU) of Huzhou Central Hospital. Patients from the MIMIC database were used as the training cohort to construct the models (from 2008 to 2019, n = 1068). Patients from Huzhou Central Hospital were utilized as the external validation cohort to evaluate the models (from June 2019 to December 2022, n = 327). In the training cohort, least absolute shrinkage and selection operator (LASSO) regression with cross-validation was employed to select features for constructing the model and subsequently established nine ML predictive models. The performance of these nine models on the external validation cohort dataset was comprehensively evaluated based on the area under the receiver operating characteristic curve (AUROC) and the optimal model was selected. A static nomogram and a web-based dynamic nomogram were presented, with a comprehensive evaluation from the perspectives of discrimination (AUROC), calibration (calibration curve) and clinical practicability (DCA curves). Results Finally, 1395 eligible patients were enrolled, including 1068 patients in the training cohort and 327 patients in the external validation cohort. In the training cohort, LASSO regression with cross-validation was employed to select features and nine models were individually constructed. Compared to the other eight models, the Lasso regularized logistic regression (Lasso-LR) model exhibited the highest AUROC (0.756) and the optimal calibration curve. The DCA curve suggested a certain clinical utility in predicting in-hospital mortality among critically ill patients with AKI undergoing CRRT. Consequently, the Lasso-LR model was the optimal model and it was visualized as a common nomogram (static nomogram) and a web-based dynamic nomogram ( https://chsyh2006.shinyapps.io/dynnomapp/ ). Discrimination, calibration and DCA curves were employed to assess the performance of the nomogram. The AUROC for the training and external validation cohorts in the nomogram model was 0.771 (95%CI: 0.743, 0.799) and 0.756 (95%CI: 0.702, 0.809), respectively. The calibration slope and Brier score for the training cohort were 1.000 and 0.195, while for the external validation cohort, they were 0.849 and 0.197, respectively. The DCA indicated that the model had a certain clinical application value. Conclusions Our study selected the optimal model and visualized it as...

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Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy

Cited by 4 publications

References 33 publications

Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review

Calcium-Citrate Anticoagulation during Continuous Renal Replacement Therapy in Patients with Metformin Intoxication: A Case Series, Mathematical Estimation of Citrate Accumulation, and Literature Review

Risk analysis of fluctuating hypercalcemia after leukapheresis in cellular therapy

Construction and evaluation of a mortality prediction model for patients with acute kidney injury undergoing continuous renal replacement therapy based on machine learning algorithms

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