Severe Metabolic Alkalosis Complicating Regional Citrate Hemodialysis

Kelleher, Stephen P.; Schulman, Gerald

doi:10.1016/s0272-6386(87)80061-6

Cited by 67 publications

(27 citation statements)

References 4 publications

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“…An ionized calcium <0.5 mmol/l has been found to effectively prevent clotting [13]. Despite the simplicity of the basic principle, the occurrence of side effects prevented its widespread acceptance [14, 15]. …”

Section: Discussionmentioning

confidence: 99%

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

Morgera¹,

Scholle²,

Voss³

et al. 2004

Nephron Clin Pract

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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.

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Section: Discussionmentioning

confidence: 99%

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

Morgera¹,

Scholle²,

Voss³

et al. 2004

Nephron Clin Pract

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“…Metabolic alkalosis has been reported to occur in therapeutic apheresis patients with renal disease who cannot adequately excrete bicarbonate [19] and in those receiving replacement fluids containing citrate, such as fresh frozen plasma [20]. As donors should have normal renal function and will not be receiving as great a citrate load, significant metabolic alkalosis should not occur [19].…”

Section: Other Acute Effects Of Citratementioning

confidence: 99%

Complications of donor apheresis

Winters

2006

J. Clin. Apheresis

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A decreasing blood donor pool in the presence of increasing blood transfusion demands has resulted in the need to maximally utilize each blood donor. This has led to a trend in the increasing use of automated blood collections. While apheresis donation shares many reactions and injuries with whole blood donation, because of the differences, unique complications also exist. Overall, evidence in the literature suggests that the frequency of reactions to apheresis donation is less than that seen in whole blood donation, though the risk of reactions requiring hospitalization is substantially greater. The most common apheresis-specific reaction is hypocalcemia due to citrate anticoagulation, which, while usually mild, has the potential for severely injuring the donor. Other reactions to apheresis donation are uncommon (e.g., hypotension) or rare (e.g., air embolism). More worrisome, and in need of additional study, are the long-term effects of apheresis donation. Recent evidence suggests that repeated apheresis platelet donations may adversely effect thrombopoiesis as well as bone mineralization. Granulocyte donation has also been implicated in unexpected long-term consequences.

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“…During hemodialysis the citrate effect is most likely confined to the extracorporeal system because about 60% of the formed citrate complexes are removed from the blood by the dialyzer. Citrate leaving the dialyzer and entering the patient's circulation is rapidly metabolized in the tricarboxylic acid pathway, predominant ly in the liver and skeletal muscle [6], Pre viously we have shown that some patients developed metabolic alkalosis during long term citrate dialysis [3], a complication that already had been noticed by others with short term citrate dialysis [7,8]. Both reducing the buffer content of the dialysate and decreasing the citrate infusion rate were effective in pre venting this side effect [4,5], These modifica tions, along with the application of a calcium supplementation rate that prevents a decrease of serum-ionized calcium, should prevent car diac arrhythmias that have been ascribed to a systemic calcium-citrate interaction imme diately after dialysis [9], Since magnesium, the other divalent cat ion in the commonly used dialysates, also forms complexes with citrate, we postulated that the anticoagulant effect of citrate could be enhanced by removing both divalent cat ions from the dialysate.…”

Section: Discussionmentioning

confidence: 99%

Citrate Anticoagulation and Divalent Cations in Hemodialysis

Janssen

Huijgens²,

Bouman³

et al. 1994

Blood Purif

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Anticoagulation with citrate in combination with a calcium-free, magnesium-containing dialysate (Ca^-Mg⁺) and intravenous supplementation of calcium is a safe procedure in renal failure patients at high risk of bleeding. Since magnesium may antagonize the anticoagulant effect of citrate by forming complexes with citrate, we studied the in vitro and in vivo interactions of calcium and magnesium on citrate anticoagulation. In the in vitro studies the activated partial thromboplastin time (APTT) was 88 s, both after addition of 3.0 µmol magnesium and after addition of 1.0 µmol calcium. The combination of 2.4 µmol magnesium and 1.0 µmol calcium achieved similar APTT values of about 35 s as 3.5 µmol calcium alone. Moreover, in a Lee-White blood clotting time, the anticoagulant effect of 7 µmol citrate was neutralized by either 10.5 µmol of a mixture of the two cations or 10.5 µmol calcium chloride alone. In 6 chronic hemodialysis patients the in vivo interactions of calcium and magnesium on citrate were measured. At the dialyzer outlet, the whole blood activated clotting time (ACT) was significantly (p < 0.05) shorter during dialysis with a Ca^-Mg⁺ dialysate than during dialysis with a calcium- and magnesium-free dialysate (Ca^-Mg^-). With the Ca^-Mg^- dialysate the ACT at the dialyzer outlet was still significantly longer than the ACT in the arterial line before citrate infusion. We also compared the serum concentrations of calcium and magnesium during the Ca^-Mg^- dialysate which was used in combination with intravenous calcium and magnesium supplementation – 0.18 and 0.08 mmol/min respectively – and during a conventional calcium- and magnesium-containing dialysate (Ca⁺Mg⁺). Serum total calcium concentrations were significantly higher during and after the Ca⁺Mg⁺ dialysate than with the Ca^-Mg^- dialysate. Plasma-ionized calcium concentrations were similar for the two dialysates at all times. However, the differences between post- and predialysis (post- minus predialysis) ionized calcium and serum magnesium with the Ca⁺Mg⁺ dialysate were significantly (p < 0.05) higher than with the Ca^-Mg^- dialysate. Thus, citrate achieves a more pronounced anticoagulation of the extracorporeal system with a Ca^-Mg^- dialysate than with a Ca^-Mg⁺ dialysate. However, the calcium and magnesium supplementation rates – 0.18 and 0.08 mmol/min respectively -result in a short-term decrease of these divalent cations which may have repercussions for the parathyroid gland function.

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Severe Metabolic Alkalosis Complicating Regional Citrate Hemodialysis

Cited by 67 publications

References 4 publications

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

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

Complications of donor apheresis

Citrate Anticoagulation and Divalent Cations in Hemodialysis

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