Safety and efficacy of regional citrate anticoagulation in continuous venovenous hemodialysis in the presence of liver failure: the Liver Citrate Anticoagulation Threshold (L-CAT) observational study

Abstract

IntroductionRegional citrate anticoagulation (RCA) for continuous renal replacement therapy is widely used in intensive care units (ICUs). However, concern exists about the safety of citrate in patients with liver failure (LF). The aim of this study was to evaluate safety and efficacy of RCA in ICU patients with varying degrees of impaired liver function.MethodsIn a multicenter, prospective, observational study, 133 patients who were treated with RCA and continuous venovenous hemodialysis (RCA-CVVHD) were included. Endpoints for safety were severe acidosis or alkalosis (pH ≤7.2 or ≥7.55, respectively) and severe hypo- or hypercalcemia (ionized calcium ≤0.9 or ≥1.5 mmol/L, respectively) of any cause. The endpoint for efficacy was filter lifetime. For analysis, patients were stratified into three predefined liver function or LF groups according to their baseline serum bilirubin level (normal liver function ≤2 mg/dl, mild LF >2 to ≤7 mg/dl, severe LF >7 mg/dl).ResultsWe included 48 patients with normal liver function, 43 with mild LF, and 42 with severe LF. LF was predominantly due to ischemia (39 %) or multiple organ dysfunction syndrome (27 %). The frequency of safety endpoints in the three patient strata did not differ: severe alkalosis (normal liver function 2 %, mild LF 0 %, severe LF 5 %; p = 0.41), severe acidosis (normal liver function 13 %, mild LF 16 %, severe LF 14 %; p = 0.95), severe hypocalcemia (normal liver function 8 %, mild LF 14 %, severe LF 12 %; p = 0.70), and severe hypercalcemia (0 % in all strata). Only three patients showed signs of impaired citrate metabolism. Overall filter patency was 49 % at 72 h. After censoring for stop of the treatment due to non-clotting causes, estimated 72-h filter survival was 96 %.ConclusionsRCA-CVVHD can be safely used in patients with LF. The technique yields excellent filter patency and thus can be recommended as first-line anticoagulation for the majority of ICU patients.Trial registrationISRCTN Registry identifier: ISRCTN92716512. Date assigned: 4 December 2008.

Implementation of a Simplified Regional Citrate Anticoagulation Protocol for Post-Dilution Continuous Hemofiltration Using a Bicarbonate Buffered, Calcium Containing Replacement Solution

“…Although RCA has been safely applied to patients with appropriate monitoring with chronic liver disease [14], in our developmental study, we excluded patients with advanced chronic liver disease, acute liver or refractory shock (table 5). In addition, we monitored the total to ionized calcium ratio twice daily to assess for citrate accumulation and if this was greater than 2.5, RCA was discontinued.…”

Super High‐Flux Continuous Venovenous Hemodialysis Using Regional Citrate Anticoagulation: Long‐Term Stability of Middle Molecule Clearance

“…Our results allow us to conclude that this hemofilter renders feasible a high and clinically effective clearance for middle molecules up to approximately 25 kDa for the whole treatment period of 72 h. Most importantly, the membrane closes rapidly for albumin so that the serum concentration of albumin did not decrease and clinically relevant albumin losses did not occur. Taken together, in citrate anticoagulated CVVHD this hemofilter yields a clinically relevant clearance of middle molecules without significant albumin loss for up to 72 h. A scheduled filter change before 72 h is therefore not required .…”

Circuit life span of continuous renal replacement therapy in critically ill patients with or without conventional anticoa-gulation: an observational prospective study

“…Por tanto, en este tipo de pacientes está plenamente justificado no utilizar ningún método de anticoagulación. Algunos trabajos recientes sugieren que el citrato podría incluso utilizarse en pacientes con fallo hepático, siempre y cuando se aumente la monitorización y se ajusten las dosis del mismo 15 . Sin embargo, nuestros resultados demuestran que asociar a este grupo de pacientes de alto riesgo lavados periódicos con suero fisiológico es una alternativa segura y eficaz a cualquier tipo de anticoagulación.…”