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

Abstract

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.

Use of High-Flow Continuous Renal Replacement Therapy with Citrate Anticoagulation to Control Intracranial Pressure by Maintaining Hypernatremia in a Patient with Acute Brain Injury and Renal Failure

“…[11][12][13] . The use of citrate anticoagulation has occasionally resulted in severe electrolyte abnormalities including hypernatremia 12,14 stemming from the large salt load found in trisodium citrate preparations. We used that excess sodium to our advantage in this case as a means to improve ICP and provide anticoagulation.…”

Citrate Anticoagulation in Hemodialysis

“…This, along with the more complex setup, presents a significant strain on staff resources and, consequently, can make citrate dialysis more costly than standard heparin dialysis. The prolonged filter patency times seen with citrate anticoagulation, however, may also introduce cost savings compared to heparin dialysis in continuous dialysis therapies [20]. The administration of buffer base in the form of citrate can further lead to metabolic alkalosis [20][21][22].…”

“…The prolonged filter patency times seen with citrate anticoagulation, however, may also introduce cost savings compared to heparin dialysis in continuous dialysis therapies [20]. The administration of buffer base in the form of citrate can further lead to metabolic alkalosis [20][21][22]. Hypernatremia can occur secondary to the additional sodium load administered with the citrate infusion (e.g., in the form of trisodium citrate, which carries 3 moles of sodium for each mole of citrate) [5,21].…”

The Acid-Base Effect of Changing Citrate Solution for Regional Anticoagulation during Continuous Veno-Venous Hemofiltration

“…Regional citrate anticoagulation (RCA) has been used for continuous renal replacement therapy (CR-RT) in patients at high risk of bleeding for more than 15 years (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). In RCA-CRRT, there are 3 major forms of citrate administration.…”

“…In RCA-CRRT, there are 3 major forms of citrate administration. One is 4% trisodium citrate (2,3,5,6,8,16,17), another is acid citrate dextrose solution (ACD) (11)(12)(13)(14)(15) and a third is citrate containing replacement fluid (4,7,9,10). Recently, a commercial citrate-containing replacement solution was developed for RCA during continuous veno-venous hemofiltration (CVVH) in Australia according to the principles described by Palsson et al (4) and Dorval et al (9) with modification toward a lower citrate concentration (Citrate A; citrate=11mmol/L) (18,19).…”