Citrate Anticoagulation for Extracorporeal Circuits: Effects on Whole Blood Coagulation Activation and Clot Formation

Calatzis, Andreas; Toepfer, Marcell; Schramm, W; Spannagl, Michael; Schiffl, Helmut

doi:10.1159/000046075

Cited by 75 publications

(55 citation statements)

References 10 publications

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“…Ionized post-filter calcium values <0.5 mmol/l have shown to effectively prevent clot formation [24]. Ionized calcium measurements can be easily performed on intensive care units and are cost-effective.…”

Section: Discussionmentioning

confidence: 99%

Regional Citrate Anticoagulation in Continuous Hemodialysis – Acid-Base and Electrolyte Balance at an Increased Dose of Dialysis

Morgera

Haase²,

Rückert³

et al. 2005

Nephron Clin Pract

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Background: Citrate anticoagulation is an excellent alternative to heparin anticoagulation for patients at high risk of bleeding requiring continuous renal replacement therapy. However, citrate anticoagulation has some potential adverse effects such as metabolic alkalosis and acidosis, hypernatremia, hypo- and hypercalcemia. Thus, most citrate anticoagulation protocols use specially designed dialysis fluids to compensate for most of these disarrangements. This study aimed at establishing a citrate anticoagulation protocol designed for a dialysate flow rate of about 2 l/h. Methods: Based on theoretical considerations we composed a dialysis fluid suitable for a 2 l/h dialysis flow rate. The dialysate contained 133 mmol/l sodium, 2 mmol/l potassium, 1.1 mmol/l magnesium, 25 mmol/l lactate, and 112.2 mmol/l chloride. Results: Twenty-three patients were included in the study. During the treatments minor flow rate adaptations were needed and the treatments were well tolerated. Filter life was appropriate (51.3 ± 24.6 h). Thirteen patients developed a mild metabolic alkalosis (pH > 7.45 plus BE > +3) which was easily counteracted by increasing the dialysis fluid flow (by increments of 500 ml). Acid-base values returned to normal within 24 h after increasing the dialysate flow. The maximum dialysate flow was 3,000 ml/h. Hypernatremia and hypocalcemia were not observed. The systemic ionized calcium concentration was successfully controlled by adjustments of a continuous calcium infusion made with respect to the results of 6-hourly measurements. Conclusion: The analyzed citrate anticoagulation protocol was well tolerated and filter lifetime was appropriate. Regional anticoagulation with trisodium citrate in combination with a customized calcium-free dialysate is a safe and effective alternative to a heparin-based anticoagulation regimen.

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Section: Discussionmentioning

confidence: 99%

Regional Citrate Anticoagulation in Continuous Hemodialysis – Acid-Base and Electrolyte Balance at an Increased Dose of Dialysis

Morgera

Haase²,

Rückert³

et al. 2005

Nephron Clin Pract

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“…Dosing of sodium citrate is done by measuring either the aPTT or the ionized calcium in the postfilter area. An ionized calcium <0.5 mmol/l has been found to effectively prevent clotting [13]. Despite the simplicity of the basic principle, the occurrence of side effects prevented its widespread acceptance [14, 15].…”

Section: Discussionmentioning

confidence: 99%

Metabolic Complications during Regional Citrate Anticoagulation in Continuous Venovenous Hemodialysis: Single-Center Experience

Morgera¹,

Scholle²,

Voss³

et al. 2004

Nephron Clin Pract

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Background: Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients at a high risk of bleeding. In a prospective, observational study we compared an established regional citrate anticoagulation protocol [Mehta R et al: Kidney Int 1990;38:976–981] versus a standard heparin anticoagulation protocol focusing on acid-base and electrolyte derangements as well as on cost effectiveness. Methods and Results: 209 patients were included in the study. In 37 patients, citrate was used as the sole anticoagulant, 87 patients received low-dose heparin plus citrate, and 85 patients received only heparin as anticoagulant. A customized dialysate solution was used for citrate-anticoagulated CRRT (no buffer, no calcium, reduced sodium concentration). Filter life was significantly higher during citrate anticoagulation compared to heparin anticoagulation (80.2 ± 60 vs. 30.2 ± 32 h; p < 0.001). No difference was found between citrate and citrate-heparin anticoagulation (p = 0.310). Metabolic alkalosis was observed in more than 50% of patients on citrate anticoagulation. Alkalosis developed within the first 72 h after initiating treatment and could be reversed in almost all cases by increasing the dialysate flow rate. Hypercalcemia was observed in 13 patients on citrate anticoagulation. Patients with impaired liver function were particularly at risk. Systemic hypocalcemia, hypernatremia, and anion gap acidosis were not observed. Citrate anticoagulation was well tolerated hemodynamically. A longer filter life during citrate anticoagulation translated into a significant cost reduction compared to standard heparin anticoagulation (p < 0.01). Conclusion: Regional anticoagulation with trisodium citrate in combination with a customized calcium-free dialysate is a safe and effective alternative to a heparin-based anticoagulation regimen.

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“…Citrate is infused into the blood at the beginning of the extracorporeal circuit and provides anticoagulation by chelating ionized calcium (iCa 2+ ). Optimal regional anticoagulation occurs when the iCa 2+ concentration in the extracorporeal circuit is <0.35 mmol/l (measured as the post-filter iCa 2+ level), correlating with citrate blood concentration of 4–6 mmol/l [2,3]. Since citrate is a small molecule, the majority of the calcium-citrate complex is freely filtered and lost in the effluent.…”

Section: Mechanismmentioning

confidence: 99%

Advances in Continuous Renal Replacement Therapy: Citrate Anticoagulation Update

Tolwani

Wille

2012

Blood Purif

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Because of the potential side effects of heparin, methods of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) have been gaining wider acceptance with the development of simplified and safer protocols. Advantages of RCA include the avoidance of systemic anticoagulation and heparin-induced thrombocytopenia. The disadvantage is that citrate can add complexity and labor intensity to CRRT. Frequent monitoring of electrolytes, ionized calcium, and acid-base status is required, due to the potential for hypernatremia, metabolic alkalosis, and systemic ionized hypocalcemia. If properly monitored, complications associated with RCA are uncommon. A variety of methods of delivering RCA are described in the literature. Overall, studies of RCA, as compared to unfractionated heparin, report better filter survival times and less bleeding. In this section, we summarize the characteristics of citrate as an anticoagulant and provide an update of citrate use in CRRT.

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Citrate Anticoagulation for Extracorporeal Circuits: Effects on Whole Blood Coagulation Activation and Clot Formation

Cited by 75 publications

References 10 publications

Regional Citrate Anticoagulation in Continuous Hemodialysis – Acid-Base and Electrolyte Balance at an Increased Dose of Dialysis

Regional Citrate Anticoagulation in Continuous Hemodialysis – Acid-Base and Electrolyte Balance at an Increased Dose of Dialysis

Metabolic Complications during Regional Citrate Anticoagulation in Continuous Venovenous Hemodialysis: Single-Center Experience

Advances in Continuous Renal Replacement Therapy: Citrate Anticoagulation Update

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