scholarly journals Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation – An observational case-control stud

2021 ◽  
Author(s):  
Agnieszka Kośka ◽  
Maciej Michał Kowalik ◽  
Anna Lango-Maziarz ◽  
Wojtek Karolak ◽  
Dariusz Jagielak ◽  
...  
Keyword(s):  
Cardiovascular Surgery ◽  
Lactate Concentration ◽  
Case Control ◽  
Anion Gap ◽  
Ionized Calcium ◽  
Magnesium Concentration ◽  
Regional Citrate Anticoagulation ◽  
Acid Base ◽  
Citrate Anticoagulation ◽  
Citrate Accumulation

Background: Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation. Methods: This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors. Results: Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors. Conclusions: The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

scholarly journals Ionic Homeostasis, Acid-base Balance and the Risk of Citrate Accumulation in Patients After Cardiovascular Surgery Treated With Continuous Veno-venous Haemofiltration With Post-dilution Regional Citrate Anticoagulation

2020 ◽  
Author(s):  
Agnieszka Kośka ◽  
Maciej Michał Kowalik ◽  
Anna Lango-Maziarz ◽  
Wojtek Karolak ◽  
Dariusz Jagielak ◽  
...  
Keyword(s):  
Renal Failure ◽  
Acute Renal Failure ◽  
Cardiovascular Surgery ◽  
Lactate Concentration ◽  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Acid Base ◽  
Citrate Anticoagulation ◽  
Citrate Accumulation ◽  
New Onset

Abstract Background: Patients with known or new-onset acute renal failure after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. The idea behind not using heparin relates to the post-operative risk of bleeding. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation.Methods: This prospective observational study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients with known chronic or new-onset acute renal failure treated with post-dilution continuous veno-venous haemofiltration (CVVH) with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients treated with CVVH with RCA were evaluated. Base excess; pH; bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations; the total to ionized calcium ratio (tCa/iCa); and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors.Results: Thirty-three (66%) patients died. In total, 235 haemofiltration sessions with a median circuit survival time of 57 hours (1-117) were evaluated. The therapies were very well balanced with regard to sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 2.5 in 11 of 246 (4.5%) readings and was significantly higher in non-survivors (p=0.037). No correlation was observed between the lactate concentration before haemofiltration and the tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased during CVVH, and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors.Conclusions: The CVVH RCA protocol provides stable sodium and chloride concentrations and a tendency towards higher pH values and bicarbonate concentrations. Supplementation with magnesium and phosphate ions is needed. The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors.Trial registration: retrospectively registered: Clinicaltrials.gov, NCT03836742.

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 Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study

2020 ◽  
Vol 49 (5) ◽  
pp. 567-575 ◽  
Author(s):  
Nathan Axel Bianchi ◽  
Marco Altarelli ◽  
Philippe Eckert ◽  
Antoine Guillaume Schneider
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Real Life ◽  
Regional Citrate Anticoagulation ◽  
Acid Base ◽  
Metabolic Complications ◽  
Citrate Anticoagulation ◽  
Randomized Controlled ◽  
Heparin Anticoagulation

Introduction: Regional citrate anticoagulation (RCA) is the recommended anticoagulation modality for continuous renal replacement therapy (CRRT). RCA was associated with a low rate of complications in randomized controlled trials. However, little is known about the type and rate of complications in real life. We sought to describe complications associated with RCA in comparison with those associated with heparin anticoagulation. Methods: In our institution, RCA has been the default anticoagulation modality for CRRT in all patients without contraindications since 2013. We have retrospectively reviewed all consecutive patients who received CRRT between January and December 2016 in our institution. For each CRRT session, we have assessed circuit duration, administered dose, as well as therapy-associated complications. Those parameters were compared according to whether the circuit was run in continuous veno-venous hemodialysis (CVVHD) mode with RCA or continuous veno-venous hemofiltration (CVVH) mode with heparin anticoagulation. Results: We analyzed 691 CRRT sessions in 121 patients. Of those 400 (57.9%) were performed in CVVHD-RCA mode and 291 (42.1%) in CVVH-Heparin Mode. Compared with ­CVVH-Heparin mode, CVVHD-RCA mode was associated with a longer circuit lifespan (median duration 54.9 interquartile range [IQR 44.6] vs. 15.3 h [IQR 22.4], p < 0.0001). It was associated with a higher rate of metabolic acidosis 77 (20.2%) vs. 18 (7.2%), (p < 0.0001), alkalosis 186 (48.7%) vs. 43 (17.1%), (p= 0.0001), and hypocalcemia 96 (25.07%) vs. 26 events (10.79%), p < 0.0001. However, the majority of these alterations were of benign or moderate severity. Only one possible citrate intoxication was observed. Conclusions: CVVHD-RCA was associated with a much longer circuit life but an increased rate of minor metabolic complications, in particular acid-base derangements. Some of these complications might have been prevented by therapy adaptation. Medical and nursing staff education is of major importance in the implementation of an RCA protocol.

Regional citrate anticoagulation and influence of recirculation on ionized calcium levels in the circuit

2019 ◽  
Vol 22 (4) ◽  
pp. 341-344
Author(s):  
Anais Degraeve ◽  
Etienne Danse ◽  
Pierre-François Laterre ◽  
Philippe Hantson ◽  
Alexis Werion
Keyword(s):  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation

Arterial Stiffness Depends on Serum Ionized Calcium Levels During Dialysis With Regional Citrate Anticoagulation

2013 ◽  
Vol 37 (5) ◽  
pp. 467-474 ◽  
Author(s):  
Matthias B. Moor ◽  
Anja Kruse ◽  
Dominik E. Uehlinger ◽  
Ute Eisenberger
Keyword(s):  
Arterial Stiffness ◽  
Ionized Calcium ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation ◽  
Serum Ionized Calcium

Regional Citrate Anticoagulation in Continuous Hemodialysis – Acid-Base and Electrolyte Balance at an Increased Dose of Dialysis

2005 ◽  
Vol 101 (4) ◽  
pp. c211-c219 ◽  
Author(s):  
Stanislao Morgera ◽  
Michael Haase ◽  
Matthias Rückert ◽  
Hanno Krieg ◽  
Marc Kastrup ◽  
...  
Keyword(s):  
Regional Citrate Anticoagulation ◽  
Electrolyte Balance ◽  
Acid Base ◽  
Citrate Anticoagulation ◽  
Continuous Hemodialysis

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.

Continuous veno-venous hemofiltration with regional citrate anticoagulation: A four-year single-center experience

2008 ◽  
Vol 31 (11) ◽  
pp. 937-943 ◽  
Author(s):  
T. Cassina ◽  
R. Mauri ◽  
A. Engeler ◽  
O. Giannini
Keyword(s):  
Clinical Practice ◽  
Renal Replacement Therapy ◽  
Life Span ◽  
Replacement Therapy ◽  
Ionized Calcium ◽  
Buffer Effect ◽  
Acid Base ◽  
Replacement Solution ◽  
Citrate Accumulation ◽  
Regional Anticoagulation

Background Hemofiltration protocols using a citrate-buffered replacement solution offer the advantage of regional anticoagulation and a buffer effect. The role played by such fluids in clinical practice is not yet well established. The risk of electrolytic disorders, acid-base imbalance, or citrate accumulation should be clarified. We report on a renal therapy protocol based on a citrate isonatremic replacement solution. Method We considered all patients needing renal replacement therapy admitted to our cardiovascular intensive care unit between January 2003 and June 2007. A citrate-buffered fluid was delivered in pre-dilution mode to a post-filter ionized calcium target ≤0.25 mmol/L. Extracorporeal blood flow was set at a constant of 140±10 ml/min. Blood calcemia was maintained by a 5% calcium-chloride solution infused into the patient. We recorded the patients' acid-base variables, ionized calcium, daily electrolytes, albumin, urea and filter life-span. Results We observed 101 consecutive patients out of 2,523; incidence 4%, overall mortality was 57% at ICU discharge. Mean replacement rate was 2,554±475 ml/h corresponding to 34±5 ml/kg/h. Mean patient ionized calcium level was 1.07±0.04 mmo/L, maintained by 13±2 ml/h of infused calcium-chloride. All other electrolytes remained in the normal range. The Stewart biophysical approach confirmed a strong anion gap of 3.1± 3 meq/L. Acid-base balance showed a buffer effect. Mean filter life-span was 52±11 h. Conclusion Renal replacement therapy based on citrate-buffered fluid may be useful in clinical practice. This methodology presented an adequate metabolic control and allowed regional anticoagulation. A sufficient calcium supply was mandatory to avoid hypocalcemia. The small strong ion gap suggested a modest citrate accumulation.

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