A target-oriented algorithm for maintaining serum calcium stability automatically in regional citrate anticoagulation

2020 ◽  
pp. 039139882098262
Author(s):  
Ruan-Mei Sheng ◽  
Wen-Biao Zhao ◽  
Li-Hong Huang ◽  
Jian-Qin Chen ◽  
Zhen-Juan Dai ◽  
...  
Keyword(s):  
Serum Calcium ◽  
Calcium Supplementation ◽  
Calcium Supplement ◽  
Regional Citrate Anticoagulation ◽  
Trial And Error ◽  
Citrate Anticoagulation ◽  
Replacement Solution ◽  
Free Replacement ◽  
Post Filter

Background: Regional citrate anticoagulation (RCA) for renal replacement therapy is widely practiced in critically ill patients. However, concern exists regarding its labor-intensiveness for monitoring and the associated hypocalcemia. In this study, we provided an algorithm for prescribing RCA and evaluated its safety in patients. Methods: During 18 hemofiltration treatments with calcium-free replacement solution, participants were randomized to receive algorithm-based or trial-and-error RCA protocol. The effluent volume, post-filter and in vivo ionized calcium (iCa), and calcium in the sera and effluents were periodically measured at an interval of 1 to 2 h. Results: For patients received algorithm-based RCA protocol, no one had a serum iCa less than 0.9 mmol/L, and none needed calcium supplement adjustment to maintain serum calcium stability. For patients accepted trial-and-error protocol, all patients had a serum iCa below 0.9 mmol/L, their serum iCa and calcium levels fluctuated dramatically, and all patients need additional calcium supplement adjustment during RCA. None of the participants showed a post-filter iCa > 0.4 mmol/L. Conclusion: We provided a safe algorithm for calculating calcium supplementation doses that could maintain serum calcium stability without additional adjustment during RCA.

scholarly journals Implementation of a Simplified Regional Citrate Anticoagulation Protocol for Post-Dilution Continuous Hemofiltration Using a Bicarbonate Buffered, Calcium Containing Replacement Solution

2016 ◽  
Vol 42 (4) ◽  
pp. 349-355 ◽  
Author(s):  
Christopher J. Kirwan ◽  
Ross Hutchison ◽  
Sherif Ghabina ◽  
Stephanie Schwarze ◽  
Abigail Beane ◽  
...  
Keyword(s):  
Metabolic Alkalosis ◽  
Calcium Supplementation ◽  
Regional Citrate Anticoagulation ◽  
Prospective Audit ◽  
Bleeding Events ◽  
Continuous Hemofiltration ◽  
Citrate Anticoagulation ◽  
Replacement Solution ◽  
Acid Citrate Dextrose ◽  
Citrate Dextrose

Background/Aims: Recent updates to the Nikkiso Aquarius continuous renal replacement therapy (CRRT) platform allowed us to develop a post-dilution protocol for regional citrate anticoagulation (RCA) using standard bicarbonate buffered, calcium containing replacement solution with acid citrate dextrose formula-A as a citrate source. Our objective was to demonstrate that the protocol was safe and effective. Methods: Prospective audit of consecutive patients receiving RCA for CRRT within intensive care unit, who were either contraindicated to heparin or had poor filter lifespan (<12 h for 2 consecutive filters) on heparin. Results: We present the first 29 patients who used 98 filters. After excluding ‘non-clot' filter loss, 50% had a duration of >27 h. Calcium supplementation was required for 30 (30%) filter circuits, in 17 of 29 (58%) patients. One patient discontinued the treatment due to metabolic alkalosis, but there were no adverse bleeding events. Conclusion: Post-dilution RCA system is effective and simple to use on the Aquarius platform and results in comparable filter life for patients relatively contraindicated to heparin.

scholarly journals Simplified Regional Citrate Anticoagulation Using a Calcium-Containing Replacement Solution for Continuous Renal Replacement Therapy: A Randomized Controlled Trial

2020 ◽  
Author(s):  
Tiantian Wei ◽  
Xin Tang ◽  
Ling Zhang ◽  
Li Lin ◽  
Peiyun Li ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Free Group ◽  
Calcium Concentration ◽  
Trisodium Citrate ◽  
Regional Citrate Anticoagulation ◽  
Citrate Solution ◽  
Citrate Anticoagulation ◽  
Function Recovery ◽  
Replacement Solution ◽  
Free Replacement

Abstract Introduction A simplified protocol for regional citrate anticoagulation (RCA) using a commercial calcium-containing replacement solution, without continuous calcium infusion, is more efficient to be used in continuous renal replacement therapy (CRRT). We aim to design a randomized clinical trial (RCT) to compare the safety and efficacy between calcium-free and calcium-containing replacement solution in CRRT with RCA. Methods Of the 64 patients receiving RCA-based post-dilution continuous venovenous hemodiafiltration (CVVHDF) enrolled from 2017-2019, 35 patients were randomized to calcium-containing group and 29 to calcium-free replacement solution group. Primary endpoint was circuit lifespan. Secondary endpoints included mortality, kidney function recovery and complications. The amount of 4% trisodium citrate solution infusion was recorded. Serum and effluent total and ionized calcium concentration were measured during CVVHDF. Results Total 149 circuits (82 in calcium-containing group and 67 in calcium-free group) and 7609 circuit hours (4335 versus 3274 hours) were included. Mean circuit lifespan was 58.1 hours (95% CI 53.8-62.4) in calcium-containing group versus 55.3 hours (95% CI 49.7-60.9, log rank P=0.89) in calcium-free group. The serum total (tCa) and ionized (iCa) calcium concentration was slightly lower in calcium-containing group during CRRT, whereas the post-filter iCa concentration was lower in calcium-free group. Moreover, mean 4% trisodium citrate solution infusion doses had no difference between groups (171.1±15.9 versus 169.0±15.1 ml/h, P=0.49). The mortality (40.0% versus 44.8%, P=0.70) and kidney function recovery rates (54.3% versus 48.3%, P=0.63) were similar in calcium-containing and calcium-free group during hospitalization, respectively. Six (3 in each group) patients showed the signs of citrate accumulation in this study. Conclusions When compared with calcium-free replacement solution, RCA based CVVHDF with calcium-containing replacement solution had similar circuit lifespan, hospital mortality and kidney outcome. Since the calcium-containing solution obviates the need for a separate venous catheter and large dose of intravenous calcium solution preparation for continuous calcium supplement, it is more convenient to be applied in RCA-CRRT practice.Trial registration Chinese Clinical Trial Registry. ChiCTR-IPR-17012629, registered on 10th September 2017. http://www.chictr.org.cn/showprojen.aspx?proj=17644

scholarly journals Discrepant post filter ionized calcium concentrations by common blood gas analyzers in CRRT using regional citrate anticoagulation

Critical Care ◽  
2015 ◽  
Vol 19 (1) ◽  
Author(s):  
Patrik Schwarzer ◽  
Sven-Olaf Kuhn ◽  
Sylvia Stracke ◽  
Matthias Gründling ◽  
Stephan Knigge ◽  
...  
Keyword(s):  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Blood Gas ◽  
Citrate Anticoagulation ◽  
Post Filter

scholarly journals Anticoagulant effects of different calcium supplementation pathways in calcium-free RCA-CVVH: a study protocol for a prospective randomized cross-over trial

2019 ◽  
Author(s):  
Biantong JIANG ◽  
Zhigang ZHANG ◽  
Xiu JIN ◽  
Haiye WANG ◽  
Yuchen WU ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Calcium Ions ◽  
Calcium Supplementation ◽  
Incidence Rates ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation ◽  
Catheter Dysfunction ◽  
Calcium Effect ◽  
The Difference ◽  
Key Aspects

Abstract Background When regional citrate anticoagulation used in continuous renal replacement therapy, one of the key aspects to achieve safe and effective extracorporeal circulation is the management of calcium ions. For calcium-free RCA-CVVH, the anticoagulant effects of different calcium supplementation pathways have not yet been explored. In this trial, we would test our hypothesis that compared with the SCV, when calcium was infused through the VL-FV, the arterial iCa2+ was lower. Methods This is a prospective randomized cross-over trial involving 24 patients undergoing RCA-CVVH. The patients were randomly divided into two groups: VL-FV—SCV group and SCV—VL-FV group. The difference of iCa2+ between arterial iCa2+ and post-filtration iCa2+ was compared. Secondary indicators included the incidence rates of catheter dysfunction and hypocalcemia. Discussion This is the first trial on the anticoagulant effects of calcium-free RCA-CVVH through different calcium supplement routes. We will confirm that the arterial iCa2 + level is slightly lower when calcium is infused in the VL-FV than in the SCV, and the incidence rates of catheter dysfunction and hypocalcemia will help us to determine which site is safer. Trial Registration CHiCTR registry: ChiCTR1800020046. Registered on 12 December 2018. (http://www.chictr.org.cn/listbycreater.aspx). Keywords: Continuous venous-venous hemofiltration, regional citrate anticoagulation, calcium, effect, safety, cross-over trial

The possibility of using effluent ionized calcium to assess regional citrate anticoagulation in continuous renal replacement therapy

2019 ◽  
Vol 43 (6) ◽  
pp. 379-384
Author(s):  
Qi Zhang ◽  
Feng Zhuang ◽  
Qichen Fan ◽  
Wenyan Yu ◽  
Feng Ding
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Altman Analysis ◽  
Bland Altman Analysis ◽  
Citrate Anticoagulation ◽  
The Mean ◽  
Post Filter

Aim: This study aimed to investigate whether effluent ionized calcium was an appropriate indicator to assess anticoagulant effect in continuous renal replacement therapy with regional citrate anticoagulation instead of post-filter ionized calcium. Methods: In total, 48 paired samples of effluent fluid and post-filter blood were obtained from critically ill patients who required continuous renal replacement therapy. All samples were taken for ionized calcium measurements and were assessed by point-of-care analyzer. Correlations and agreements between two methods were performed by Pearson linear analysis and Bland–Altman analysis accordingly. Results: The mean post-filter ionized calcium was 0.42 ± 0.12 mmol/L, and mean ionized calcium level of effluent fluid was 0.39 ± 0.11 mmol/L. The ionized calcium level of effluent fluid was significantly correlated with post-filter ionized calcium in all continuous renal replacement therapy patients. Bland–Altman analysis showed that the mean difference of ionized calcium between two sampling sites in all continuous renal replacement therapy patients was −0.02 mmol/L with 95% confidence interval ranging from −0.09 to 0.04 mmol/L. The significant correlations and agreements were also demonstrated in continuous veno-venous hemofiltration, continuous veno-venous hemodialysis, and continuous veno-venous hemodiafiltration modalities separately. Conclusion: The effluent ionized calcium could be a considerable substitute for post-filter ionized calcium to monitor the validity of regional citrate anticoagulation in continuous renal replacement therapy with less blood loss.

Optimized Calcium Supplementation Approach for Regional Citrate Anticoagulation

Nephron ◽  
2018 ◽  
Vol 141 (2) ◽  
pp. 119-127 ◽  
Author(s):  
Wenyan Yu ◽  
Feng Zhuang ◽  
Shuai Ma ◽  
Qichen Fan ◽  
Mingli Zhu ◽  
...  
Keyword(s):  
Calcium Supplementation ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation
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