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

Raimundo, Mário; Crichton, Siobhan; Lei, Katie; Sanderson, Barnaby; Smith, Joseph; Brooks, John M.; Ng, Josephine; Smith, Joanna Lemmich; McKenzie, Catherine; Beale, Richard; Dickie, Helen A.; Ostermann, Marlies

doi:10.1159/000355860

Cited by 16 publications

(9 citation statements)

References 50 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Our study evaluated iPTH, as well as oxPTH and noxPTH, over the first 24 h of citrate CVVH. Median baseline iPTH in our study was lower than the 264 pg/ml reported in the Van der Voort study [ 2 ], but higher than the 67 pg/ml in the study by Raimundo et al [ 3 ]. At 24 h, median iPTH in our study dropped, while it rose to 399 pg/ml in the van der Voort study and was 89 pg/ml in the Raimundo study.…”

Section: Discussioncontrasting

confidence: 83%

“…Even a minor decrease in systemic iCa can trigger PTH release, mobilizing Ca from skeletal stores within minutes [ 7 , 8 ]. A negative Ca balance during citrate-based CRRT has been observed in three studies [ 2 , 4 , 5 ], and in two a rise in intact (i)PTH has been reported [ 2 , 3 ]. Although it seems rational to replace the lost amount of Ca, in clinical practice Ca replacement is often adjusted to the systemic iCa concentration, despite the fact that the optimal iCa concentration during critical illness is not known.…”

Section: Introductionmentioning

confidence: 99%

“…This method is based on pre-filter administration of citrate, which lowers ionized calcium (iCa) by chelation, thereby inhibiting the clotting cascade within the filter, and on the concomitant replacement of calcium (Ca) via the post-filter circuit or a separate line. Insufficient replacement of the increased loss of Ca as Ca citrate complexes in the effluent may lead to a negative Ca balance, systemic hypocalcemia [2][3][4][5] and further activation of parathormone (PTH), which may already be activated due to renal dysfunction. Until now calcium balance during citrate CVVH has not been studied in a randomized way.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D status, a randomized controlled trial

et al. 2021

View full text Add to dashboard Cite

Background Regional citrate anticoagulation may cause a negative calcium balance, systemic hypocalcemia and parathormone (PTH) activation but randomzed studies are not available. Aim was to determine the effect of citrate dose on calcium (Ca) and magnesium (Mg) balance, PTH and Vitamin D. Methods Single center prospective randomized study. Patients, requiring continuous venovenous hemofiltration (CVVH) with citrate, randomized to low dose citrate (2.5 mmol/L) vs. high dose (4.5 mmol/L) for 24 h, targeting post-filter ionized calcium (pfiCa) of 0.325–0.4 mmol/L vs. 0.2–0.275 mmol/L, using the Prismaflex® algorithm with 100% postfilter calcium replacement. Extra physician-ordered Ca and Mg supplementation was performed aiming at systemic iCa > 1.0 mmol/L. Arterial blood, effluent and post-filter aliquots were taken for balance calculations (area under the curve), intact (i), oxidized (ox) and non-oxidized (nox) PTH, 25-hydroxy-Vitamin D (25D) and 1,25-dihydroxy-Vitamin D (1,25D). Results 35 patients were analyzed, 17 to high, 18 to low citrate. Mean 24-h Ca balance was - 9.72 mmol/d (standard error 1.70) in the high vs − 1.18 mmol/d (se 1.70)) (p = 0.002) in the low citrate group and 24-h Mg-balance was − 25.99 (se 2.10) mmol/d vs. -17.63 (se 2.10) mmol/d (p = 0.008) respectively. Physician-ordered Ca supplementation, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH, oxPTH or noxPTH were not different between groups. Over 24 h, median PTH decreased from 222 (25th–75th percentile 140–384) to 162 (111–265) pg/ml (p = 0.002); oxPTH from 192 (124–353) to 154 pg/ml (87–231), p = 0.002. NoxPTH did not change significantly. Mean 25 D (standard deviation), decreased from 36.5 (11.8) to 33.3 (11.2) nmol/l (p = 0.003), 1,25D rose from 40.9 pg/ml (30.7) to 43.2 (30.7) pg/ml (p = 0.046), without differences between groups. Conclusions A higher citrate dose caused a more negative CVVH Ca balance than a lower dose, due to a higher effluent Calcium loss. Physician-ordered Ca supplementation, targeting a systemic iCa > 1.0 mmol/L, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH and oxPTH declined, suggesting decreased oxidative stress, while noxPTH did not change. 25D decreased while 1,25-D rose. Mg balance was negative in both groups, more so in the high citrate group. Trial registration ClinicalTrials.gov: NCT02194569. Registered 18 July 2014.

show abstract

Section: Discussioncontrasting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D status, a randomized controlled trial

et al. 2021

View full text Add to dashboard Cite

show abstract

“…The negative Ca balance and systemic hypocalcemia in citrate CVVH can lead to further activation of parathormone (PTH) which may already have been activated due to renal dysfunction [25,28,32]. Van der Voort found that median systemic iPTH was significantly higher in the citrate group (iCa at 0.8-1.0 mmol/l) compared to both the nadroparin group and the control group without renal failure [25].…”

Section: Hormonal Effects Of Citratementioning

confidence: 99%

Unapparent systemic effects of regional anticoagulation with citrate in continuous renal replacement therapy: a narrative review

Boer

Verbrugghe

Hoste

et al. 2023

Ann. Intensive Care

View full text Add to dashboard Cite

The use of citrate, through reversible binding of calcium, has become the preferred choice for anticoagulation in continuous renal replacement therapy in the critically ill patient. Though generally considered as very efficacious in acute kidney injury, this type of anticoagulation can cause acid–base disorders as well as citrate accumulation and overload, phenomena which have been well described. The purpose of this narrative review is to provide an overview of some other, non-anticoagulation effects of citrate chelation during its use as anticoagulant. We highlight the effects seen on the calcium balance and hormonal status, phosphate and magnesium balance, as well as oxidative stress resulting from these unapparent effects. As most of these data on these non-anticoagulation effects have been obtained in small observational studies, new and larger studies documenting both short- and long-term effects should be undertaken. Subsequent future guidelines for citrate-based continuous renal replacement therapy should take not only the metabolic but also these unapparent effects into account.

show abstract

“…Targeting a higher plasma calcium concentration seems to suppress PTH release, which may limit calcium mobilization from bone. However, PTH measurements in critically ill patients should be interpreted with caution, because the normal assay measures oxidized PTH as well, which is biologically inactive [ 22 ]. Some modern CRRT devices incorporate an algorithm with a 100 % calcium compensation option, which seems attractive.…”

Section: Calciummentioning

confidence: 99%

Metabolic Aspects of CRRT

Straaten

Chua

Joannès-Boyau

et al. 2015

Acute Nephrology for the Critical Care Physician

View full text Add to dashboard Cite

Acidosis is common in patients with AKI in the ICU and often associated with acidemia. It is typically secondary to the accumulation of lactate, chloride and unmeasured anions. Its correction appears desirable and can be more reliably and safely achieved with CRRT. Use of bicarbonate-based fl uids is safest as the initial approach. However, lactate-and citrate-buffered fl uids can also correct acidosis if appropriately metabolized by the liver and other key organs. CRRT can also be used to correct extreme acidosis in the absence of a major degree of renal impairment. As

show abstract

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

Cited by 16 publications

References 50 publications

Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D status, a randomized controlled trial

Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D status, a randomized controlled trial

Unapparent systemic effects of regional anticoagulation with citrate in continuous renal replacement therapy: a narrative review

Metabolic Aspects of CRRT

Contact Info

Product

Resources

About