Ionized Magnesium and Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy

Zakharchenko, Mychajlo; Leden, Pavel; Rulíšek, Jan; Los, Ferdinand; Brodská, Helena; Borggrefe, Martin

doi:10.1159/000440972

Cited by 22 publications

(21 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Brain found a significantly negative magnesium balance using dialysis/replacement fluids containing 0.5 mmol Mg tot per liter [ 7 ]. In our previous research on ionised magnesium we found similar negative magnesium balance when using fluids with 0.75 mmol/l Mg tot per liter [ 9 ]. With regards to rather difficult assessment of magnesium deficit in critically ill RCA may lead to inapparent losses of magnesium and depletion of its relatively low body pool [ 6 , 8 , 18 ].…”

Section: Introductionmentioning

confidence: 67%

“…The daily magnesium substitution is a matter of debate with regards to reported deficit of intracellular magnesium in general population and in intensive care patients in particular [ 4 – 8 ]. Thus CRRT in ICU frequently requires early magnesium substitution and the requirements are further increased with regional citrate anticoagulation (RCA)[ 7 , 9 ].…”

Section: Introductionmentioning

confidence: 99%

“…Various citrate protocols has shown either mild cummulation, deficit or even balance of total calcium mostly depending on the intensity of calcium substitution [ 15 – 17 ]. RCA is always accompanied by meticulous calcium substitution, much less attention is paid to changes and substitution of magnesium which is chelated by citrate similarly to calcium [ 7 , 9 ]. The balance of total magnesium (Mg tot ) is not well explored under various modalities and solutions used with citrate anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill

et al. 2016

Self Cite

View full text Add to dashboard Cite

BackgroundThe requirements for magnesium (Mg) supplementation increase under regional citrate anticoagulation (RCA) because citrate acts by chelation of bivalent cations within the blood circuit. The level of magnesium in commercially available fluids for continuous renal replacement therapy (CRRT) may not be sufficient to prevent hypomagnesemia.MethodsPatients (n = 45) on CRRT (2,000 ml/h, blood flow (Qb) 100 ml/min) with RCA modality (4% trisodium citrate) using calcium free fluid with 0.75 mmol/l of Mg with additional magnesium substitution were observed after switch to the calcium-free fluid with magnesium concentration of 1.50 mmol/l (n = 42) and no extra magnesium replenishment. All patients had renal indications for CRRT, were treated with the same devices, filters and the same postfilter ionized calcium endpoint (<0.4 mmol/l) of prefilter citrate dosage. Under the high level Mg fluid the Qb, dosages of citrate and CRRT were consequently escalated in 9h steps to test various settings.ResultsMedian balance of Mg was -0.91 (-1.18 to -0.53) mmol/h with Mg 0.75 mmol/l and 0.2 (0.06–0.35) mmol/h when fluid with Mg 1.50 mmol/l was used. It was close to zero (0.02 (-0.12–0.18) mmol/h) with higher blood flow and dosage of citrate, increased again to 0.15 (-0.11–0.25) mmol/h with 3,000 ml/h of high magnesium containing fluid (p<0.001). The arterial levels of Mg were mildly increased after the change for high level magnesium containing fluid (p<0.01).ConclusionsCompared to ordinary dialysis fluid the mildly hypermagnesemic fluid provided even balances and adequate levels within ordinary configurations of CRRT with RCA and without a need for extra magnesium replenishment.Trial RegistrationClinicalTrials.gov Identifier: NCT01361581

show abstract

Section: Introductionmentioning

confidence: 67%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill

et al. 2016

Self Cite

View full text Add to dashboard Cite

show abstract

“…This can lead to hypomagnesaemia if magnesium replenishment with the substitution uid is not adequate. It was observed that post-lter magnesium concentrations decrease in a manner similar to the concentrations of calcium ions under RCA [24]. When using substitution uid containing 0.5 mmol/L magnesium, a tendency towards a decreased magnesium concentration was observed during haemo ltration treatment.…”

Section: Magnesiummentioning

confidence: 79%

Ionic Homeostasis, Acid-base Balance and the Risk of Citrate Accumulation in Patients After Cardiovascular Surgery Treated With Continuous Veno-venous Haemofiltration With Post-dilution Regional Citrate Anticoagulation

Kośka¹,

Kowalik²,

Lango-Maziarz³

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Patients with known or new-onset acute renal failure after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. The idea behind not using heparin relates to the post-operative risk of bleeding. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation.Methods: This prospective observational study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients with known chronic or new-onset acute renal failure treated with post-dilution continuous veno-venous haemofiltration (CVVH) with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients treated with CVVH with RCA were evaluated. Base excess; pH; bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations; the total to ionized calcium ratio (tCa/iCa); and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors.Results: Thirty-three (66%) patients died. In total, 235 haemofiltration sessions with a median circuit survival time of 57 hours (1-117) were evaluated. The therapies were very well balanced with regard to sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 2.5 in 11 of 246 (4.5%) readings and was significantly higher in non-survivors (p=0.037). No correlation was observed between the lactate concentration before haemofiltration and the tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased during CVVH, and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors.Conclusions: The CVVH RCA protocol provides stable sodium and chloride concentrations and a tendency towards higher pH values and bicarbonate concentrations. Supplementation with magnesium and phosphate ions is needed. The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors.Trial registration: retrospectively registered: Clinicaltrials.gov, NCT03836742.

show abstract

“…Second, this study was limited to a single center with a single CRRT machine and filter; the effect of different CRRT machines and filters on the extracorporeal removal of n-Ca is unclear. Third, the optimized calcium DOI: 10.1159/000494693 supplementation approach did not consider the effect of RCA on bone metabolism and magnesium metabolism for patients receiving long-term RCA-CRRT [24][25][26].…”

Section: Discussionmentioning

confidence: 99%

Optimized Calcium Supplementation Approach for Regional Citrate Anticoagulation

Fan

et al. 2018

Nephron

View full text Add to dashboard Cite

Background: It has been confirmed that regional citrate anticoagulation (RCA) plays an effective role in extracorporeal anticoagulation. The current trial-and-error calcium supplementation approach, with intensive monitoring of calcium levels, restricts the widespread use of RCA. Therefore, this study aimed to optimize the calcium supplementation approach for RCA. Methods: Patients requiring RCA treatment for various reasons were included. Citrate was infused into the arterial port, and the ionized calcium levels in the extracorporeal circulation tubes and body were monitored to maintain them within the target range. Linear regression equations between the clearance of non-protein bound calcium (n-Ca) and prescribed effluent rate were determined; the ratio of the n-Ca concentration to total calcium concentration (fa) after the infusion of citrate was also calculated. Then, we estimated a simplified calcium supplementation approach. Results: Positive correlations were found between the clearance of n-Ca and effluent rate both during continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemofiltration (CVVH; R²: 0.66 and 0.65, respectively, p < 0.01). The fa values at the pre-filter point and after infusion of citrate were constants, but the values differed from CVVHD to CVVH. For CVVHD, fa was 0.93, and for CVVH, fa was 0.80. Using the extracorporeal removal characteristics of n-Ca, the amount of extracorporeally removed calcium per mmol per hour can be quantified with a simplified equation. Conclusion: The optimized calcium supplementation approach could provide a more precise and practical method to estimate the amount of extracorporeal calcium removal with regard to different modalities and dosages of RCA.

show abstract

Ionized Magnesium and Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy

Cited by 22 publications

References 30 publications

The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill

The Effects of High Level Magnesium Dialysis/Substitution Fluid on Magnesium Homeostasis under Regional Citrate Anticoagulation in Critically Ill

Ionic Homeostasis, Acid-base Balance and the Risk of Citrate Accumulation in Patients After Cardiovascular Surgery Treated With Continuous Veno-venous Haemofiltration With Post-dilution Regional Citrate Anticoagulation

Optimized Calcium Supplementation Approach for Regional Citrate Anticoagulation

Contact Info

Product

Resources

About