Sustained low-efficiency dialysis with regional citrate anticoagulation in medical intensive care unit patients with liver failure: A prospective study

Lahmer, Tobias; Messer, Marlena; Rasch, Sebastian; Beitz, Analena; Schnappauf, Christopher; Schmid, Roland M.; Huber, Wolfgang

doi:10.1016/j.jcrc.2015.06.006

Cited by 30 publications

(29 citation statements)

References 23 publications

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“…We found no correlation between LDCA and standard laboratory liver function parameters, which is in line with the results of previous studies 9,12 . We predicted that age may be negatively correlated with LDCA, due to decreased muscle mass and weakened mitochondria 23,24 , but that is not supported by our study.…”

Section: Discussionsupporting

confidence: 93%

A novel predictive score for citrate accumulation among patients receiving artificial liver support system therapy with regional citrate anticoagulation

Chen

Liu

et al. 2020

Sci Rep

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Patients with liver failure may suffer citrate accumulation when using regional citrate anticoagulation for artificial liver support system therapy (RCA-ALSS therapy). This study aimed to develop a predictive scoring system to stratify the risk of citrate accumulation. A total of 338 patients treated with RCA-ALSS therapy were retrospectively enrolled and randomly divided into derivation and validation cohorts. Longer duration of citrate accumulation (LDCA) was defined as the presence of citrate accumulation 2 h after RCA-ALSS therapy. Four baseline variables were found to be independently associated with LDCA: gender, international normalized ratio of prothrombin time, serum creatinine, and serum chloride. A predictive R-CA model and its simplified R-CA score were developed. The R-CA model (AUROC = 0.848) was found to be superior to the MELD score (AUROC = 0.725; p = 0.022) and other univariate predictors (AUROCs < 0.700; all p ≤ 0.001) in predicting LDCA. The R-CA score (AUROC = 0.803) was as capable as the R-CA model (p = 0.369) and the MELD score (p = 0.174), and was superior to other univariate predictors (all p < 0.05) in predicting LDCA. An R-CA score of 0-2 had a negative predictive value of 90.2% for LDCA. Our R-CA score reliably predicts LDCA in patients with RCA-ALSS therapy, and it is easy to use. Patients with R-CA score of 0-2 can safely receive RCA-ALSS therapy, while others should be carefully evaluated before treatment. Trial registration: Chinese Clinical Trial Registry, ChiCTR2000029179. Registered 17 January 2020, https ://www.chict r.org.cn/showp roj.aspx?proj=48084. Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical deterioration and high mortality. Artificial liver support system (ALSS) therapy is an available treatment for patients with ACLF and is a bridge to liver transplantation 1. However, the optimal extracorporeal anticoagulation regimen for ALSS therapy remains uncertain. Regional citrate anticoagulation (RCA) is now the preferred anticoagulation method for patients underwent continuous renal replacement therapy (CRRT) 2,3. RCA seems also safe and feasible for patients with liver failure, and citrate accumulation is well tolerated by them 4-14. The blood purification techniques used in these patients include a dialysis technique that can remove citrate directly. Our previous study suggests that RCA is relatively safe and effective in patients with ACLF receiving double plasma molecular adsorption system plus plasma exchange (DPMAS plus PE) therapy that does not include dialysis and filtration techniques 15. However, transient citrate accumulation was found in all patients due to PE therapy in both groups and RCA in RCA group, and it remained much higher in RCA group than that in heparin anticoagulation group 2 h after the conclusion of the ALSS therapy (34.0% vs. 7.4%, p = 0.000) 15. Citrate accumulation is a feared and potentially lethal complication of RCA manifesting as an increased ratio of total calcium (Ca tot) to ionized calcium (Ca ...

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Section: Discussionsupporting

confidence: 93%

A novel predictive score for citrate accumulation among patients receiving artificial liver support system therapy with regional citrate anticoagulation

Chen

Liu

et al. 2020

Sci Rep

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“…In assessing metabolic complications of citrate anticoagulation, in particular the duration of dialysis is of central importance because in prolonged CRRT high cumulative doses of citrate are administered. However, in the literature, only short dialysis periods are described [ 3 , 8 , 23 – 26 ]. The recently published liver citrate anticoagulation threshold (L-CAT) trial convincingly showed the safety of CRRT-RCA in patients with severely impaired liver function [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, baseline liver function parameters should be predictive regarding citrate accumulation during CRRT with RCA. However, most standard laboratory liver function parameters showed poor predictive capabilities [ 3 , 6 , 26 ]. This raises the question whether impaired hepatic function is really the main reason for accumulation of citrate.…”

Section: Discussionmentioning

confidence: 99%

Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction

et al. 2017

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BackgroundAs of 2009, anticoagulation with citrate was standard practice in continuous renal replacement therapy (CRRT) for critically ill patients at the University Medical Centre of Saarland, Germany. Partial hepatic metabolism of citrate means accumulation may occur during CRRT in critically ill patients with impaired liver function. The aim of this study was to evaluate the actual influence of hepatic function on citrate-associated complications during long-term CRRT.MethodsIn a retrospective study conducted between January 2009 and November 2012, all cases of dialysis therapy performed in the interdisciplinary surgical intensive care unit were analysed. Inclusion criteria were CRRT and regional anticoagulation with citrate, pronounced liver dysfunction, and pathologically reduced indocyanine green plasma disappearance rate (ICG-PDR).ResultsA total of 1339 CRRTs were performed in 69 critically ill patients with liver failure. At admission, the mean Model for End-stage Liver Disease score was 19.2, and the mean ICG-PDR was 9.8%. Eight patients were treated with liver replacement therapy, and 30 underwent transplants. The mortality rate was 40%. The mean duration of dialysis was 19.4 days, and the circuit patency was 62.2 h. Accumulation of citrate was detected indirectly by total serum calcium/ionised serum calcium (tCa/iCa) ratio > 2.4. This was noted in 16 patients (23.2%). Dialysis had not to be discontinued for metabolic disorder or accumulation of citrate in any case. In 26% of cases, metabolic alkalosis occurred with pH > 7.5. Interestingly, no correlation between citrate accumulation and liver function parameters was detected. Moreover, most standard laboratory liver function parameters showed poor predictive capabilities for accumulation of citrate.ConclusionsOur findings indicate that extra-hepatic metabolism of citrate seems to exist, avoiding in most cases citrate accumulation in critically ill patients despite impaired liver function. Because the citric acid cycle is oxygen-dependent, disturbed microcirculation would result in inadequate citrate metabolism. Raising the tCa/iCa ratio would therefore be an indicator of severity of illness and mortality rather than of liver failure. However, further studies are warranted for confirmation.

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“…Several cohort studies have reported the use of RCA in patients with LF underwent CVVH and reported the incidences of citrate accumulation. In the study by Slowinski et al [12], Sponholz et al [35], and Lahmer et al [36], the incidences of citrate accumulation were reported to be 2.2%, 3%, and 4%, respectively. And, no citrate accumulation was observed in the study by Durao et al and De Vico et al [14,30].…”

Section: Plos Onementioning

confidence: 94%

Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study

Bai

et al. 2020

PLoS ONE

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Objective There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients. Methods The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes. Results In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2-47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26-0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups.

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Sustained low-efficiency dialysis with regional citrate anticoagulation in medical intensive care unit patients with liver failure: A prospective study

Cited by 30 publications

References 23 publications

A novel predictive score for citrate accumulation among patients receiving artificial liver support system therapy with regional citrate anticoagulation

A novel predictive score for citrate accumulation among patients receiving artificial liver support system therapy with regional citrate anticoagulation

Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction

Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study

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