Bone resorption and “relative” immobilization hypercalcemia with prolonged continuous renal replacement therapy and citrate anticoagulation

Wang, Pei Li; Meyer, Mary M.; Orloff, Susan L.; Anderson, Sharon

doi:10.1053/j.ajkd.2004.09.001

Cited by 26 publications

(26 citation statements)

References 14 publications

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“…This equilibrium may be deranged during citrate-based CRRT in critically ill patients if systemic [Ca i ] is allowed to fall outside the physiologic range. This may be particularly relevant if prolonged therapy is necessary [13]. Van der Voort et al [14] observed a rise in systemic [Ca i ] from 0.89 mmol/l at 24 h to 1.09 mmol/l at 48 h after initiation of CRRT without an increase in calcium administration.…”

Section: Discussionmentioning

confidence: 99%

“…Low serum [Ca i ] is the main physiologic trigger for PTH release. Although the role of PTH in ICU patients is still unclear, high PTH levels and disturbed calcium homeostasis are associated with bone reabsorption and poor outcomes in acutely ill patients [12,13,16,17,21,22,23]. Two small studies in critically ill patients receiving citrate-based CRRT reported a negative daily calcium balance and raised PTH levels, when aiming for relatively low systemic [Ca i ] [14,15].…”

Section: Discussionmentioning

confidence: 99%

“…In patients with normal kidney function, PTH also increases tubular calcium reabsorption and stimulates the conversion of 25- hydroxyvitamin D 3 to 1,25-dihydroxyvitamin D 3 . Studies in critically ill patients with acute kidney injury treated with citrate-based CRRT reported a negative calcium balance and a rise in intact PTH (PTHi) levels when accepting systemic [Ca i ] between 0.8 and 1.1 mmol/l [13,14,15]. The clinical consequences of hypocalcaemia and hyperparathyroidism have never been systematically studied in critically ill.…”

Section: Introductionmentioning

confidence: 99%

“…The clinical consequences of hypocalcaemia and hyperparathyroidism have never been systematically studied in critically ill. However, low [Ca i ] and high PTH levels correlate with increased mortality in critically ill patients [16,17] and severe bone reabsorption has been described after prolonged citrate-based CRRT [13]. …”

Section: Introductionmentioning

confidence: 99%

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Maintaining Normal Levels of Ionized Calcium during Citrate-Based Renal Replacement Therapy Is Associated with Stable Parathyroid Hormone Levels

et al. 2013

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Background/Aims: Citrate is an effective anticoagulant during continuous renal replacement therapy (CRRT). Previous studies showed raised parathyroid hormone (PTH) levels when aiming for serum ionized calcium [Ca_i] between 0.8 and 1.1 mmol/l. Our objective was to assess whether citrate-based CRRT with physiologic target systemic [Ca_i] between 1.12 and 1.20 mmol/l could maintain stable PTH levels. Methods: Measurement of intact PTH (PTHi) in 30 consecutive critically ill patients treated with citrate-based CRRT. Results: Thirty patients [mean age: 70.4 (SD 11.3) years; 56.7% males] were enrolled. Mean serum [Ca_i] was 1.16 mmol/l (SD 0.09), 1.13 mmol/l (SD 0.09), 1.17 mmol/l (SD 0.05) and 1.16 mmol/l (SD 0.04) at baseline, 12, 24 and 48 h, respectively (p = 0.29). Median PTHi levels (interquartile range) at baseline, 12, 24 and 48 h were 66.5 (43-111), 109 (59.5-151.5), 88.5 (47-133) and 85 pg/ml (53-140), respectively. The differences between baseline and 12 h and across all time points were statistically not significant (p = 0.16 and p = 0.49, respectively). In a mixed-effects model, each 0.1 mmol/l increase in serum [Ca_i] was associated with a 31.2% decrease in PTHi (p < 0.001). Results were unchanged after adjustment for age, gender, magnesium, phosphate, arterial pH and time spent on CRRT. Conclusions: Maintaining systemic [Ca_i] within the physiologic range was associated with stable PTHi levels.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Maintaining Normal Levels of Ionized Calcium during Citrate-Based Renal Replacement Therapy Is Associated with Stable Parathyroid Hormone Levels

et al. 2013

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“…Although the significance of PTH secretion in this setting is still unclear, concerns about the potential harmful effects on bone metabolism have been expressed (10). Indeed, recruitment of body calcium stores as compensation for negative calcium balance could lead to severe bone reabsorption during prolonged RCA CRRT, which was reported after discontinuation of calcium supplementation in patients with immobilization-related hypercalcemia, possibly masked by calcium chelation during RCA (96). Although additional investigations are required to establish the most appropriate calcium substitution strategies, adequate calcium replacement aimed at avoiding episodes of hypocalcemia should help prevent bone loss during prolonged RCA (10,93).…”

Section: Rca: Electrolyte Balance Acid-base Status and Effects On Bmentioning

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

124

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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