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

Abstract

Background/Aims: Recent updates to the Nikkiso Aquarius continuous renal replacement therapy (CRRT) platform allowed us to develop a post-dilution protocol for regional citrate anticoagulation (RCA) using standard bicarbonate buffered, calcium containing replacement solution with acid citrate dextrose formula-A as a citrate source. Our objective was to demonstrate that the protocol was safe and effective. Methods: Prospective audit of consecutive patients receiving RCA for CRRT within intensive care unit, who were either contraindicated to heparin or had poor filter lifespan (<12 h for 2 consecutive filters) on heparin. Results: We present the first 29 patients who used 98 filters. After excluding ‘non-clot' filter loss, 50% had a duration of >27 h. Calcium supplementation was required for 30 (30%) filter circuits, in 17 of 29 (58%) patients. One patient discontinued the treatment due to metabolic alkalosis, but there were no adverse bleeding events. Conclusion: Post-dilution RCA system is effective and simple to use on the Aquarius platform and results in comparable filter life for patients relatively contraindicated to heparin.

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit

“…The present results compare well with similar studies, using this protocol in a general intensive care unit (ICU) population (27 h) and postoperative cardiac surgical patients who received RCA predilution continuous hemofiltration (48 h), continuous hemodiafiltration with RCA or heparin (50-58 h) and continuous hemodialysis with RCA (39-61 h) [10,[14][15][16][17][18][19][20].…”

“…If the plasma pH increased above 7.5 or bicarbonate concentration above 40 mmol/L the hemofiltration dose was decreased from the initial 35 mL/kg/h to 25 mL/kg/h. If metabolic alkalosis persisted, the citrate dose was reduced and if this did not resolve the issue within 3 h RCA was stopped [10]. Primary endpoint of this study was to assess filter lifespan in post dilution CVVH with RCA in cardiovascular surgery patients.…”

Effects of hemoperfusion and continuous renal replacement therapy on patient survival following paraquat poisoning

“…HP is currently considered the only effective approach for treating PQ intoxication, and has been broadly applied in clinical settings [16, 24, 25]. As in HP, CRRT achieves movement of solutes across a semi-permeable membrane [26, 27]. Due to CRRT’s slow diffusion, its convection overcomes the reduced removal rate of larger solutes seen in HP.…”

Optimized Calcium Supplementation Approach for Regional Citrate Anticoagulation

“…Generally, citrate is infused into the arterial catheter port to maintain the level of iCa in extracorporeal circulation between 0.2 and 0.4 mmol/L. Simultaneously, an infusion of calcium supplementation into the venous catheter port maintains iCa in the plasma within the range of 1.0-1.2 mmol/L [8,9]. Precise calcium supplementation would make RCA safe and effective; in contrast, imprecise calcium supplementation could cause serious complications, including hypocalcemia, hypercalcemia, and filter clotting [9][10][11][12].…”