Citrate pharmacokinetics at high levels of circuit citratemia during coupled plasma filtration adsorption

Mariano, Filippo; Morselli, Maurizio; Holló, Zsuzsanna; Agostini, Fulvio; Stella, Maurizio; Biancone, Luigi

doi:10.1093/ndt/gfv290

Cited by 14 publications

(17 citation statements)

References 29 publications

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“…Then, the filtered plasma is returned to the patient through a dialysis hemofilter for further solute and fluid removal [ 96 ]. Circuit anticoagulation can be performed with either regular heparin-based anticoagulants or regional citrate anticoagulation, as septic patients with AKI are at an increased risk of bleeding similarly to patients with concomitant traumatic or burn injuries [ 97 , 98 ].…”

Section: Plasma Exchange In the Treatment Of Septic Akimentioning

confidence: 99%

Renal Replacement Techniques in Septic Shock

Hellman

Uusalo

Järvisalo

2021

IJMS

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Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to an infection; it carries a risk for mortality, considerably exceeding that of a mere infection. Sepsis is the leading cause for acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) in intensive care unit (ICU) patients. Almost every second critically ill patient with sepsis will develop AKI. In septic shock, the dysregulated host response to infectious pathogens leads to a cytokine storm with uncontrolled production and release of humoral proinflammatory mediators that evoke cellular toxicity and promote the development of organ dysfunction and increased mortality. In addition to treating AKI, RRT techniques can be employed for extracorporeal adsorption of inflammatory mediators using specifically developed adsorption membranes, hemoperfusion sorbent cartridges or columns; these techniques are intended to decrease the level and early deleterious effects of circulating proinflammatory cytokines and endotoxins during the first hours and days of septic shock treatment, in order to improve patient outcomes. Several methods and devices, such as high cut-off membranes, the Oxiris®-AN69 membrane, CytoSorb® and HA380 cytokine hemoadsorption, polymyxin B endotoxin adsorption, and plasmapheresis have been examined in small study series or are under evaluation as ways of improving patient outcomes in septic shock. However, to date, the data on actual outcome benefits have remained controversial, as discussed in this review.

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Section: Plasma Exchange In the Treatment Of Septic Akimentioning

confidence: 99%

Renal Replacement Techniques in Septic Shock

Hellman

Uusalo

Järvisalo

2021

IJMS

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“…Usually to achieve this adequate range of ionized calcium, the citrate concentration in treated blood is between 3 and 4 mmol/L. 19 As such, active bleeding is not a contraindication for RCA since citrate’s impact on systemic hemostasis would only occur with systemic ionized calcium concentrations not compatible with life. During our treatments, the lowest systemic ionized calcium observed was 0.99 mmol/L (normal range: 1.00-1.35 mmol/L).…”

Section: Discussionmentioning

confidence: 99%

Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

Reis

Freitas

Reis

et al. 2021

Can J Kidney Health Dis

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Rationale: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events. Presenting concerns of the patient: (1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm3 even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided. Diagnoses: (1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement. Interventions: Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation. Outcomes: All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter. Teaching points: In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.

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“…89 Importantly, liver failure per se is not a contraindication for regional citrate anticoagulation (RCA) since citrate metabolization also takes place in the myocytes and the renal cortex, [90][91][92][93] in both CPFA and PAP citrate can be used. 94 A retrospective analysis compared the bilirubin removal capacity of PAP versus MARS. The PAP group had 66 individuals and the MARS group 14 individuals.…”

Section: Pl a S Ma Adsorp Ti On Perfus I Onmentioning

confidence: 99%

Continuous renal replacement therapy and extended indications

Ronco

Reis

2021

Seminars in Dialysis

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Initially developed to replace kidney function in severely ill newborns/infants, and then diverted to severely ill adult patients, 1 continuous renal replacement therapy (CRRT) is now applied to support different organs apart from the kidney in a myriad of clinical conditions such as sepsis, 2 acute liver failure (ALF), 3 acute respiratory distress syndrome (ARDS), 4-6 and cardiogenic shock. 7 The extended indications for CRRT and the concept of sequential extracorporeal therapies 8 are intrinsically related. The individualization of care and selection of treatment candidates based on clinical and molecular phenotypes increases the probability of benefit for each of the proposed blood purification techniques 9-15 (Figure 1).In sepsis, the removal of damage-associated molecular patterns (e.g. cytokines) and pathogen-associated molecular patterns (e.g. endotoxins) might reduce the burden of the disease. 16 In liver failure, CRRT reduces the risk of ammonia-related neurotoxicity while artificial liver support systems effectively reduce bilirubin and bile acids concentrations. 3 In ARDS, extracorporeal CO 2 removal (ECCO 2 R) allows the application of ultra-protective ventilation avoiding deleterious consequences of hypercapnia and reducing the risk of ventilator-associated lung injury. [17][18][19] In cardiogenic shock and cardiac surgery in which shifts in fluid balance are poorly tolerated, CRRT might mitigate further myocardial damage. 20,21

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Citrate pharmacokinetics at high levels of circuit citratemia during coupled plasma filtration adsorption

Abstract: These results demonstrated that in refractory septic shock patients on CPFA at circuit citratemia of 6 mmol/L both HDF predilution and HF pre/postdilution were the best dialysis modalities to maintain a normal systemic citratemia through a high rate of citrate loss in the effluent.

Cited by 14 publications

References 29 publications

Renal Replacement Techniques in Septic Shock

Renal Replacement Techniques in Septic Shock

Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

Continuous renal replacement therapy and extended indications

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