Unexpected severe hypocalcemia during continuous venovenous hemodialysis with regional citrate anticoagulation

Meier‐Kriesche, Herwig‐Ulf; Finkel, Kevin W.; Gitomer, Jeremy J.; DuBose, Thomas D.

doi:10.1016/s0272-6386(99)70249-0

Cited by 65 publications

(49 citation statements)

References 10 publications

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“…To estimate the accumulation degree of citrates, iCa is a sensitive indicator, but not adequately specific and could be related to other causes [29]. Whereas, the increase of tCa/iCa ratio correlates best with plasma citrates level [30].…”

Section: Discussionmentioning

confidence: 99%

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Yu¹,

Peng²,

Cen³

et al. 2018

Kidney Blood Press Res

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Background/Aims: Continuous renal replacement therapy (CRRT) is a treatment for acute kidney injury (AKI) patients. It has become a controversy about whether patients with liver dysfunction should perform CRRT with regional citrate anticoagulation (RCA). Methods: This retrospective observational study enrolled 145 AKI patients (275 CRRT sessions) who received CRRT with RCA and had no history of chronic liver disease. Circuit survival time, blood pressure, trans-membrane pressure (TMP), acid-base and electrolyte status were recorded and analyzed. The severity of liver dysfunction was determined by total bilirubin (TBil) and international normalized ratio (INR), while the accumulation degree of citrates was quantified by total/ ionized calcium (tCa/iCa) raito. Results: Our results showed that there was no correlation of tCa/iCa ratio with TBil or INR. And tCa/iCa ratio was not related to the disturbances of pH, lactates, sodium, magnesium, blood pressure or TMP despite that high tCa/iCa ratios might be related to the decrease of circuit survival time. TBil did not correlate with the above indexes, except for lactates levels. INR did not correlate with the above indexes except for lactates levels and blood pressure. In addition, neither was TBil, INR, nor tCa/iCa ratio, related with fatal outcomes (22.76% of the patients). Conclusion: The present study demonstrated that, with proper monitoring and adjustment of citrates and calcium infusion, applying RCA in CRRT is reasonably safe for AKI patients with acute liver dysfunction, as long as circuit time stays below roughly 50 hours.

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Section: Discussionmentioning

confidence: 99%

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Yu¹,

Peng²,

Cen³

et al. 2018

Kidney Blood Press Res

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“…Moreover, inadequate citrate metabolism may be associated with a fall in ionized serum calcium levels as the result of impaired calcium release from the calcium-citrate complexes. As a consequence, progressively higher calcium infusion rates may be required to maintain the ionized calcium concentration within physiologic limits, and there may be a disproportionate rise in both the total systemic calcium concentration and the total-to-ionized calcium ratio (the calcium ratio) (11,22,44,52). In clinical practice, because the calcium ratio is related to the blood citrate concentration, it is commonly accepted as an indirect index of citrate accumulation during RCA (45,48,(53)(54)(55).…”

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

confidence: 99%

“…Thus, assessment of the calcium ratio along with accurate monitoring of acid-base status, systemic ionized calcium levels, and changes in calcium substitution requirements is the most reasonable approach for early detection of citrate accumulation. Close attention to the early signs of citrate accumulation is mandatory in high-risk patients (21); in particular, because the main risk of citrate accumulation is a rapid fall in the systemic ionized calcium level, potentially resulting in serious complications, such as hypotension and arrhythmias (10,52), the usual calcium monitoring intervals (4-6 hours) as well as the timing of the calcium ratio assessment should be shortened in patients who may have impaired citrate metabolism (e.g., those with severe liver failure and tissue hypoperfusion). Despite these concerns, there is increasing evidence of the safety of RCA in patients with severe liver failure/liver transplant with or without molecular adsorbent recirculating system support (53,(56)(57)(58) or severe septic shock with liver hypoperfusion (47).…”

Section: Citrate Accumulation Risk and Rca Monitoringmentioning

confidence: 99%

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

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Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

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“…Any changes to the fluid removal rate, replacement fluid rate, or dialysate flow rate resulted in reciprocal adjustments to ensure a constant effluent rate of 35 ml/kg per h. Dialyzer filters were changed routinely every 72 h per the manufacturer's recommendations. Monitoring for citrate toxicity was performed as described previously (18).…”

Section: Monitoring Of Therapymentioning

confidence: 99%

A Practical Citrate Anticoagulation Continuous Venovenous Hemodiafiltration Protocol for Metabolic Control and High Solute Clearance

Tolwani

Prendergast

Speer

et al. 2006

Clinical Journal of the American Society of Nephrology

109

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Obstacles to the widespread use of continuous renal replacement therapy (CRRT) include the need for anticoagulation, customized solutions, and complex protocols that carry an attendant risk for error, raise cost, and increase pharmacy and nursing workload. However, high solute clearance using CRRT with an effluent rate of 35 ml/kg per h has also recently been associated with improved survival in critically ill patients with acute renal failure. No published CRRT protocols using dilute regional citrate anticoagulation have achieved adequate metabolic control, effective anticoagulation, and high solute clearance in a practical, user-friendly, and economical manner. The safety and the efficacy of continuous venovenous hemodiafiltration at effluent rates of 35 ml/kg per h in critically ill acute renal failure patients were evaluated prospectively using a standardized bicarbonate-based dialysate; a systemic calcium infusion; and two separate trisodium citrate replacement solutions, a 0.67% solution and a 0.5% solution. All patients achieved adequate metabolic control, the desired effluent rate of 35 ml/kg per h, and high solute clearance. Use of the 0.67% citrate replacement solution resulted in mild alkalosis, whereas the 0.5% solution maintained appropriate acid-base balance. There was no difference in dialyzer survival between the 0.67 and 0.5% citrate groups (80 versus 82%; P ‫؍‬ 0.60, Kaplan-Meier analysis). Dilute regional citrate as part of a CRRT protocol with a standard 25-mmol/L bicarbonate dialysate provides adequate metabolic control, high diffusive and convective clearance, and excellent dialyzer patency in a practical and cost-effective manner.

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Unexpected severe hypocalcemia during continuous venovenous hemodialysis with regional citrate anticoagulation

Cited by 65 publications

References 10 publications

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Applying Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy for Acute Kidney Injury Patients with Acute Liver Dysfunction: a Retrospective Observational Study

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

A Practical Citrate Anticoagulation Continuous Venovenous Hemodiafiltration Protocol for Metabolic Control and High Solute Clearance

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