Feasibility of Citrate Dialysis in Hyponatremia: A Case Series

Abstract

Background: Correcting hyponatremia too quickly can lead to osmotic demyelination syndrome. During citrate dialysis, a significant sodium load is brought to the prefilter. We reviewed the impact of this sodium load on the evolution of sodium levels in patients undergoing continuous renal replacement therapy with citrate anticoagulation. Materials and Methods: The medical records of 5 patients with hyponatremia who received dialysis with citrate anticoagulation, over a 10-year period, were reviewed. The sodium of the dialysate and of the reinjection fluid was adapted according to the serum sodium level recommended by the guidelines of the time. Data from the first 24 h after initiation of dialysis was evaluated. Results: The difference in serum sodium levels between day 1 and day 2 was statistically significant, with a rise of 7.8 ± 3.7 mmol/L. Discussion: The mean serum sodium increase in our series of patients did not exceed the increase of 10–12 mEq/L/day permitted by the guidelines. The excess sodium was absorbed by the filter. Conclusion: In this small series of patients, with adjustment of the sodium concentration of dialysate and reinjection fluid, the use of citrate was found to be safe.

Continuous hemodialysis with citrate anticoagulation and standard dialysate for managing acute kidney injury in patients with moderate to severe hyponatremia—A retrospective study

“…A mean correction rate of 7.8 mmol/L/24 h in plasma sodium concentration was achieved at the cost of increased labor intensity and concerns over sterility of the modification of dialysate and replacement fluid bags. Furthermore, all the patients in their case series had plasma sodium exceeding 130 mmol/L at CVVHDF initiation in contrast to our current study 8 . The use of standard dialysate and citrate solutions for CVVHD in the management of hyponatremia has not been tested in a clinical study before probably because of concerns over excessive sodium correction due to the high sodium concentration of the citrate anticoagulation fluid.…”

“…The sodium concentration of dialysate and replacement fluids can be modified, although not easily as in intermittent hemodialysis. Previous studies have reported favorable results in the management of hyponatremia with CRRT techniques 6‐8 …”

“…Especially considering the high incidence of hyponatremia in critically ill patient populations 1,2 . Recently, Redant et al (2020) published a report on CVVHDF with citrate‐calcium anticoagulation and modified low‐sodium dialysate and replacement fluids in the management of AKI and coincident hyponatremia in a small case series of five patients 8 . A mean correction rate of 7.8 mmol/L/24 h in plasma sodium concentration was achieved at the cost of increased labor intensity and concerns over sterility of the modification of dialysate and replacement fluid bags.…”

“…The use of CVVHD with standard citrate‐calcium anticoagulation and dialysate in the management of critically ill AKI patients with hyponatremia appears to be feasible but our study raises some concerns over the safety of the technique. Although the use of standard solutions for CVVHD is simple and reduces the workload and contamination risk associated with the preparation of dialysate and replacement solutions with diluted sodium concentration, the risk for excessive sodium correction might be intuitively higher due to the high sodium load of the standard solutions 8,11 . This hypothesis, however, is yet to be tested in a clinical trial.…”

“…To the best of our knowledge only a single previous small case series is available on the use of citrate‐calcium anticoagulation and CVVHDF to treat AKI in hyponatremic patients. The study by Redant et al (2020) included only five patients and the dialysate and replacement fluids were diluted to avoid excessive sodium correction 8 and the mean increase in sodium concentration during the first 24 hours was 7.8 mmol/L. The increased risk for rapid sodium correction during citrate‐anticoagulation is due to the high sodium concentration of the trisodium citrate solution.…”