Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation

Swartz, Richard D.; Pasko, Deborah A.; O’Toole, John F.; Starmann, B.

doi:10.5414/cnp61134

Cited by 85 publications

(58 citation statements)

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“…The citrate infusion rate is titrated to maintain low ionized calcium levels in the extracorporeal circuit that are sufficient to achieve full blood anticoagulation (i.e., 0.3-0.4 mmol/L) (11,22); this target is generally attained with a citrate level in the extracorporeal circuit of approximately 3 mmol/L (Figure 1) (32). Because both citrate anion and trisodium citrate complexes have low molecular weight (198 and 258, respectively), high sieving coefficients (0.85-1), and high diffusive/convective clearances, a significant quantity of the citrate anions and calcium-citrate complexes is lost in the effluent fluid (33,34). As a result, calcium infusion is usually needed to replace calcium losses and maintain systemic ionized calcium levels within the normal range ( Figure 1).…”

Section: Rca: Basic Principles and Citrate Metabolismmentioning

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

128

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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Section: Rca: Basic Principles and Citrate Metabolismmentioning

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

128

130

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“…The safety of using citrate anticoagulation during continuous renal replacement therapy in patients with severe rhabdomyolysis remains uncertain. It is a routine practice to administer calcium to the patient during continuous renal replacement therapy with citrate anticoagulation because 35-50% of the citrate-calcium complex is removed in the effluent dialysate [4]. Acceptable systemic ionised calcium levels are usually easily achieved via a separate intravenous calcium infusion of < 3 mmol.h )1 .…”

Section: Discussionmentioning

confidence: 99%

“…Major side effects from citrate anticoagulation are uncommon but may include citrate accumulation in patients whom have impaired excretion pathways or metabolism. While 35-50% of citrate is removed in the effluent dialysate, the remaining 50-65% is metabolised into bicarbonate [4]. The hepatic system is the major metabolic pathway for citrate although the kidneys and muscle tissue also metabolise citrate to a lesser extent.…”

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confidence: 99%

Profound hypocalcaemia in a patient being anticoagulated with citrate for continuous renal replacement therapy

Morgan

2009

Anaesthesia

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SummaryCitrate, as an anticoagulant for continuous renal replacement therapy in critically ill patients, has some potential advantages over heparin, including a prolonged dialysis filter life and reduced risk of bleeding. The key parameter involved in monitoring the adequacy and safety of citrate anticoagulation during continuous renal replacement therapy pertains to the ionised and total plasma calcium levels. We report a case of severe systemic hypocalcaemia during continuous renal replacement therapy with citrate anticoagulation resulting from relentless sequestration of calcium due to undiagnosed evolving rhabdomyolysis. Although excessive systemic citrate accumulation can also cause hypocalcaemia, this complication was not observed in our patient. While an acceptable lower limit of ionised calcium remains unknown, severe rhabdomyolysis needs to be considered when a patient's ionised calcium levels are not responsive to standard calcium replacement therapy during continuous renal replacement therapy using citrate anticoagulation in critically ill patients.

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“…We implemented a modified standard RCA protocol from our CRRT protocols (derived from that of Swartz et al [18] from the University of Michigan Medical Center) into our SLED practice, because the operational characteristics for SLED were more similar to CRRT than they were for intermittent HD, which had a different RCA protocol. We calculated the mmol/h citrate infused during CRRT with a Qb rate of 180 ml/min.…”

Section: Patientsmentioning

confidence: 99%

Safety and Efficacy of Regional Citrate Anticoagulation During 8-Hour Sustained Low-Efficiency Dialysis

Clark

Schulman

Golper

2008

Clinical Journal of the American Society of Nephrology

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Background and objectives: Patients who may benefit from sustained low-efficiency dialysis therapy are often at risk for bleeding. A safe and simple "regional" anticoagulation strategy would be beneficial. The modification of existing regional citrate anticoagulation protocols to typically performed 8-h sustained low-efficiency dialysis is necessary.Design, setting, participants, & measurements: Sustained low-efficiency dialysis was performed at blood and dialysate rates of 250 and 300 ml/min, respectively. The circuit was anticoagulated with 4% sodium citrate (citrate 136, sodium 408 mmol/L) and reversed with CaCl 2 . Every 2 h, electrolytes, ionized circuit, and patient calcium were monitored during the first two versions. The second version differed by an increased infusion of CaCl 2 and lower infusion of citrate, both by 10%. The third version measured only laboratory values before and after sustained low-efficiency dialysis.Results Conclusions: Compared with continuous renal replacement therapy, one must increase the calcium infusion because of the more efficient removal of the calcium citrate complex. Safe and effective regional citrate anticoagulation can be performed in 8-h sustained low-efficiency dialysis without metabolic complications with laboratory surveillance only before and after sustained low-efficiency dialysis treatment; however, certain safeguards are mandatory.

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Improving the delivery of continuous renal replacement therapy using regional citrate anticoagulation

Cited by 85 publications

References 0 publications

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Profound hypocalcaemia in a patient being anticoagulated with citrate for continuous renal replacement therapy

Safety and Efficacy of Regional Citrate Anticoagulation During 8-Hour Sustained Low-Efficiency Dialysis

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