Treatment of Metabolic Alkalosis during Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation

Kindgen‐Milles, Detlef; Amman, Jordan; Kleinekofort, Wolfgang; Morgera, Stanislao

doi:10.1177/039139880803100414

Cited by 23 publications

(17 citation statements)

References 7 publications

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“…Using this algorithm, acidosis can be corrected by increasing blood flow (and at the same time citrate load) in relation to dialysate flow. Alkalosis can be corrected by decreasing the blood flow (this way decreasing citrate load) (12,30).…”

Section: Discussionmentioning

confidence: 99%

Regional Citrate Anticoagulation for High Volume Continuous Venovenous Hemodialysis in Surgical Patients With High Bleeding Risk

et al. 2012

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Acute kidney injury requiring renal replacement therapy occurs in up to 10% of all intensive care unit patients. Those who are hemodynamically unstable are often treated with continuous renal replacement therapy requiring continuous anticoagulation of the extracorporeal circuit. This is usually achieved by infusion of unfractionated heparin, which subsequently increases the risk of bleeding. To avoid systemic anticoagulation for continuous renal replacement therapy, regional anticoagulation with citrate has been introduced. We studied safety and efficacy of regional citrate anticoagulation for continuous venovenous hemodialysis in surgical patients requiring high dialysis doses. This was an observational prospective study in a 40-bed surgical intensive care unit at a university hospital. During a 12-month study period, all consecutive critically ill patients with high risk of bleeding requiring continuous renal replacement therapy continuous renal replacement therapy were treated with citrate anticoagulation for continuous venovenous hemodialysis. Prescribed dialysis dose was 45 mL/kg per h with a 10% increase for expected downtime. We studied filter lifetime, delivered dialysis dose, control of acid-base status, bleeding episodes, and adverse effects, that is, citrate intolerance. The total number of filters analyzed in 75 patients was 100. Mean (± standard deviation) filter running time was 78 ± 25 h. Fifty-one circuits had to be renewed because of extended filter running time (96 ± 18 h), 33 discontinued for reasons not related to renal replacement therapy (62 ± 19 h), and 13 due to filter clotting (58 ± 18 h). The mean dialysis dose during the first 72 h was 49 ± 14 mL/kg per h. Overall, acid-base status after 72 h was well controlled in 62% of patients, metabolic alkalosis (pH > 7.45) occurred in 29%, and metabolic acidosis (pH < 7.35) in 9%. In one patient, treatment was stopped because of citrate accumulation. Citrate intoxication or overt bleeding episodes were not observed. Regional citrate anticoagulation for continuous venovenous hemodialysis is a safe and effective method to deliver a high dialysis dose in critically ill patients with a high risk of bleeding. Filter patency was excellent, acid-base status was well controlled, and clinically relevant adverse effects were not observed. Therefore, citrate anticoagulated continuous venovenous hemodialysis is a useful treatment option for patients with acute kidney injury requiring high dialysis doses and at risk of bleeding.

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Section: Discussionmentioning

confidence: 99%

Regional Citrate Anticoagulation for High Volume Continuous Venovenous Hemodialysis in Surgical Patients With High Bleeding Risk

et al. 2012

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“…In addition, because citrate is used as a preservative for stored blood and blood products, CRRT patients in receipt of very large volumes of transfused blood may develop metabolic alkalosis while being treated with RCA. Alkalosis can be managed by either decreasing the blood flow rate, and so allowing a decrease in the citrate infusion rate into the patient, or by decreasing the infusion of citrate, or additionally by increasing citrate and bicarbonate losses in the dialysate effluent by increasing the dialysate flow, or by either reducing bicarbonate in the dialysate/replacement solutions [ 32 ] or infusing 0.9% sodium chloride as pre- or post-replacement fluid [ 33 ]. An alternative approach to reduce the risk of alkalosis has been to use less citrate, aiming for a lower pre-dialyzer/haemofilter citrate concentration of 3–4 mmol/l with a corresponding higher ionized calcium of ∼0.4 mmol/l, rather than the usual target of 4–6 mmol/l of citrate and an ionized post-filter calcium of <0.3 mmol/l, and accepting a shorter CRRT circuit life.…”

Section: Metabolic Complications Associated With Citrate Anticoagulatmentioning

confidence: 99%

Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit

Davenport

Tolwani

2009

Clinical Kidney Journal

150

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Continuous forms of renal replacement therapy (CRRT) have become established as the treatment of choice for supporting critically ill patients with acute kidney injury. Typically, these patients have activation of the coagulation cascades, peripheral mononuclear cells and platelets, but also a reduction in natural anticoagulants, and are therefore prothrombotic. For continuous modes of renal replacement therapy to be effective, in terms of both effective solute clearance and also fluid removal, the extracorporeal circuits must operate continuously. Thus, preventing clotting in the CRRT circuit is a key goal to effective patient management. As these patients may also be at increased risk of bleeding, regional anticoagulation with citrate is increasing in popularity, particularly following the introduction of commercially available CRRT machines and fluids specifically designed for citrate anticoagulation. Although regional anticoagulation with citrate provides many advantages over other systemic anticoagulants, excess citrate may lead to both metabolic complications, ranging from acidosis to alkalosis and may also potentially expose patients to electrolyte disturbances due to hyper- and hyponatraemia and hyper- and hypocalcaemia.

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“…Most dialysis-based protocols take the bicarbonate generation from infused citrate into account and use lower bicarbonate concentrations in the dialysate [ 6 ]. On one hand, such protocols usually allow better control of the acid–base state [ 10 ]; on the other hand, the metabolism of citrate is essential to maintain sufficient delivery of bicarbonate. As a consequence, in such protocols, impaired citrate metabolism translates into metabolic acidosis.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2015

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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.

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Treatment of Metabolic Alkalosis during Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation

Cited by 23 publications

References 7 publications

Regional Citrate Anticoagulation for High Volume Continuous Venovenous Hemodialysis in Surgical Patients With High Bleeding Risk

Regional Citrate Anticoagulation for High Volume Continuous Venovenous Hemodialysis in Surgical Patients With High Bleeding Risk

Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit

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

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