Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance

BACKGROUND: Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic cit...

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Autores principales: Yessayan, Lenar, Sohaney, Ryann, Puri, Vidhit, Wagner, Benjamin, Riddle, Amy, Dickinson, Sharon, Napolitano, Lena, Heung, Michael, Humes, David, Szamosfalvi, Balazs
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249839/
https://www.ncbi.nlm.nih.gov/pubmed/34215201
http://dx.doi.org/10.1186/s12882-021-02443-6
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author Yessayan, Lenar
Sohaney, Ryann
Puri, Vidhit
Wagner, Benjamin
Riddle, Amy
Dickinson, Sharon
Napolitano, Lena
Heung, Michael
Humes, David
Szamosfalvi, Balazs
author_facet Yessayan, Lenar
Sohaney, Ryann
Puri, Vidhit
Wagner, Benjamin
Riddle, Amy
Dickinson, Sharon
Napolitano, Lena
Heung, Michael
Humes, David
Szamosfalvi, Balazs
author_sort Yessayan, Lenar
collection PubMed
description BACKGROUND: Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of “single starting calcium infusion rate for all patients” puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS: This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA “Non-shock” protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS: Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th–75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91–2.13). CONCLUSIONS: The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of “one starting dose for all” reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.
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spelling pubmed-82498392021-07-02 Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance Yessayan, Lenar Sohaney, Ryann Puri, Vidhit Wagner, Benjamin Riddle, Amy Dickinson, Sharon Napolitano, Lena Heung, Michael Humes, David Szamosfalvi, Balazs BMC Nephrol Research BACKGROUND: Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of “single starting calcium infusion rate for all patients” puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h. METHODS: This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA “Non-shock” protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications. RESULTS: Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th–75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91–2.13). CONCLUSIONS: The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of “one starting dose for all” reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels. BioMed Central 2021-07-02 /pmc/articles/PMC8249839/ /pubmed/34215201 http://dx.doi.org/10.1186/s12882-021-02443-6 Text en © The Author(s) 2021 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Yessayan, Lenar
Sohaney, Ryann
Puri, Vidhit
Wagner, Benjamin
Riddle, Amy
Dickinson, Sharon
Napolitano, Lena
Heung, Michael
Humes, David
Szamosfalvi, Balazs
Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title_full Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title_fullStr Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title_full_unstemmed Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title_short Regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance
title_sort regional citrate anticoagulation “non-shock” protocol with pre-calculated flow settings for patients with at least 6 l/hour liver citrate clearance
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249839/
https://www.ncbi.nlm.nih.gov/pubmed/34215201
http://dx.doi.org/10.1186/s12882-021-02443-6
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