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Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

RATIONALE: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus r...

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Autores principales: Reis, Thiago, Ramos de Freitas, Geraldo Rubens, Reis, Fábio, Cascelli de Azevedo, Maria Letícia, Dias, Priscila, Figueiredo Santos, Diêgo Fernando, Vivanco Vergara, Rodrigo Alfredo, Sgarabotto, Luca, Reis da Silva Filho, Evandro, Ronco, Claudio
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SAGE Publications 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8579339/
https://www.ncbi.nlm.nih.gov/pubmed/34777842
http://dx.doi.org/10.1177/20543581211054736
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author Reis, Thiago
Ramos de Freitas, Geraldo Rubens
Reis, Fábio
Cascelli de Azevedo, Maria Letícia
Dias, Priscila
Figueiredo Santos, Diêgo Fernando
Vivanco Vergara, Rodrigo Alfredo
Sgarabotto, Luca
Reis da Silva Filho, Evandro
Ronco, Claudio
author_facet Reis, Thiago
Ramos de Freitas, Geraldo Rubens
Reis, Fábio
Cascelli de Azevedo, Maria Letícia
Dias, Priscila
Figueiredo Santos, Diêgo Fernando
Vivanco Vergara, Rodrigo Alfredo
Sgarabotto, Luca
Reis da Silva Filho, Evandro
Ronco, Claudio
author_sort Reis, Thiago
collection PubMed
description RATIONALE: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events. PRESENTING CONCERNS OF THE PATIENT: (1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm(3) even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided. DIAGNOSES: (1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement. INTERVENTIONS: Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation. OUTCOMES: All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter. TEACHING POINTS: In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.
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spelling pubmed-85793392021-11-11 Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series Reis, Thiago Ramos de Freitas, Geraldo Rubens Reis, Fábio Cascelli de Azevedo, Maria Letícia Dias, Priscila Figueiredo Santos, Diêgo Fernando Vivanco Vergara, Rodrigo Alfredo Sgarabotto, Luca Reis da Silva Filho, Evandro Ronco, Claudio Can J Kidney Health Dis Educational Case Report RATIONALE: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events. PRESENTING CONCERNS OF THE PATIENT: (1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm(3) even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided. DIAGNOSES: (1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement. INTERVENTIONS: Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation. OUTCOMES: All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter. TEACHING POINTS: In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions. SAGE Publications 2021-11-07 /pmc/articles/PMC8579339/ /pubmed/34777842 http://dx.doi.org/10.1177/20543581211054736 Text en © The Author(s) 2021 https://creativecommons.org/licenses/by-nc/4.0/This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
spellingShingle Educational Case Report
Reis, Thiago
Ramos de Freitas, Geraldo Rubens
Reis, Fábio
Cascelli de Azevedo, Maria Letícia
Dias, Priscila
Figueiredo Santos, Diêgo Fernando
Vivanco Vergara, Rodrigo Alfredo
Sgarabotto, Luca
Reis da Silva Filho, Evandro
Ronco, Claudio
Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_full Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_fullStr Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_full_unstemmed Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_short Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_sort regional hypertonic citrate anticoagulation in membrane therapeutic plasma exchange: a case series
topic Educational Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8579339/
https://www.ncbi.nlm.nih.gov/pubmed/34777842
http://dx.doi.org/10.1177/20543581211054736
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