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Simplified Citrate Anticoagulation for CRRT Without Calcium Replacement.

Broman M, Klarin B, Sandin K, Carlsson O, Wieslander A, Sternby J, Godaly G - ASAIO J. (2015 Jul-Aug)

Bottom Line: This was successfully achieved by including citrate and calcium in all CRRT solutions.All postfilter ionized calcium levels were <0.5 mmol/L, that is, an anticoagulation effect was reached.This pilot study suggests that it is possible to perform regional citrate anticoagulation without the need for separate calcium infusion during CRRT.

View Article: PubMed Central - PubMed

Affiliation: From the *Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden; †Gambro Lundia AB, Lund, Sweden; ‡Department of Nephrology, Lund University, Lund, Sweden; and §Department of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden.

ABSTRACT
Since 2012, citrate anticoagulation is the recommended anticoagulation strategy for continuous renal replacement therapy (CRRT). The main drawback using citrate as anticoagulant compared with heparin is the need for calcium replacement and the rigorous control of calcium levels. This study investigated the possibility to achieve anticoagulation while eliminating the need for calcium replacement. This was successfully achieved by including citrate and calcium in all CRRT solutions. Thereby the total calcium concentration was kept constant throughout the extracorporeal circuit, whereas the ionized calcium was kept at low levels enough to avoid clotting. Being a completely new concept, only five patients with acute renal failure were included in a short, prospective, intensely supervised nonrandomized pilot study. Systemic electrolyte levels and acid-base parameters were stable and remained within physiologic levels. Ionized calcium levels declined slightly initially but stabilized at 1.1 mmol/L. Plasma citrate concentrations stabilized at approximately 0.6 mmol/L. All postfilter ionized calcium levels were <0.5 mmol/L, that is, an anticoagulation effect was reached. All filter pressures were normal indicating no clotting problems, and no visible clotting was observed. No calcium replacement was needed. This pilot study suggests that it is possible to perform regional citrate anticoagulation without the need for separate calcium infusion during CRRT.

No MeSH data available.


Related in: MedlinePlus

Schematic presentation of flow rates and compositions of the study solutions.
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Figure 3: Schematic presentation of flow rates and compositions of the study solutions.

Mentions: For safety reasons, this pilot clinical trial of a completely new concept included only a few patients (up to 10) treated for 5 hours. The patients were subjected to intense monitoring including blood sampling, and a physician present bedside. Patients undergoing CRRT at the general intensive care unit at Skane University Hospital in Lund, Sweden, with acute renal failure of risk, injury, failure, loss, and end-stage kidney disease criteria class F were recruited to the study between February 29 and May 22, 2012. Patients were excluded if they were younger than 18 years, were under guardianship, had chronic kidney disease, had HIV and/or hepatitis B or C, and participated in other studies during the study period that could affect the study outcome. The patients were monitored during at least 10 hours of CRRT before inclusion to assure the stability of vital physiologic parameters and a well-functioning central dialysis catheter and were returned to conventional treatment after the study period (Figure 2). Nutrition was given enteral and/or parenteral to hemodynamically stable patients during the study period. Study dialysis details are shown in Figure 3. The prescribed dialysis doses per kilogram of body weight and hour (not corrected for predilution) were 27–53 mL/kg/hr (mean 35), depending on the patient weight and prescribed weight loss. The study products were produced and sterile filtrated at APL in Umeå, Sweden.


Simplified Citrate Anticoagulation for CRRT Without Calcium Replacement.

Broman M, Klarin B, Sandin K, Carlsson O, Wieslander A, Sternby J, Godaly G - ASAIO J. (2015 Jul-Aug)

Schematic presentation of flow rates and compositions of the study solutions.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4487873&req=5

Figure 3: Schematic presentation of flow rates and compositions of the study solutions.
Mentions: For safety reasons, this pilot clinical trial of a completely new concept included only a few patients (up to 10) treated for 5 hours. The patients were subjected to intense monitoring including blood sampling, and a physician present bedside. Patients undergoing CRRT at the general intensive care unit at Skane University Hospital in Lund, Sweden, with acute renal failure of risk, injury, failure, loss, and end-stage kidney disease criteria class F were recruited to the study between February 29 and May 22, 2012. Patients were excluded if they were younger than 18 years, were under guardianship, had chronic kidney disease, had HIV and/or hepatitis B or C, and participated in other studies during the study period that could affect the study outcome. The patients were monitored during at least 10 hours of CRRT before inclusion to assure the stability of vital physiologic parameters and a well-functioning central dialysis catheter and were returned to conventional treatment after the study period (Figure 2). Nutrition was given enteral and/or parenteral to hemodynamically stable patients during the study period. Study dialysis details are shown in Figure 3. The prescribed dialysis doses per kilogram of body weight and hour (not corrected for predilution) were 27–53 mL/kg/hr (mean 35), depending on the patient weight and prescribed weight loss. The study products were produced and sterile filtrated at APL in Umeå, Sweden.

Bottom Line: This was successfully achieved by including citrate and calcium in all CRRT solutions.All postfilter ionized calcium levels were <0.5 mmol/L, that is, an anticoagulation effect was reached.This pilot study suggests that it is possible to perform regional citrate anticoagulation without the need for separate calcium infusion during CRRT.

View Article: PubMed Central - PubMed

Affiliation: From the *Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden; †Gambro Lundia AB, Lund, Sweden; ‡Department of Nephrology, Lund University, Lund, Sweden; and §Department of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden.

ABSTRACT
Since 2012, citrate anticoagulation is the recommended anticoagulation strategy for continuous renal replacement therapy (CRRT). The main drawback using citrate as anticoagulant compared with heparin is the need for calcium replacement and the rigorous control of calcium levels. This study investigated the possibility to achieve anticoagulation while eliminating the need for calcium replacement. This was successfully achieved by including citrate and calcium in all CRRT solutions. Thereby the total calcium concentration was kept constant throughout the extracorporeal circuit, whereas the ionized calcium was kept at low levels enough to avoid clotting. Being a completely new concept, only five patients with acute renal failure were included in a short, prospective, intensely supervised nonrandomized pilot study. Systemic electrolyte levels and acid-base parameters were stable and remained within physiologic levels. Ionized calcium levels declined slightly initially but stabilized at 1.1 mmol/L. Plasma citrate concentrations stabilized at approximately 0.6 mmol/L. All postfilter ionized calcium levels were <0.5 mmol/L, that is, an anticoagulation effect was reached. All filter pressures were normal indicating no clotting problems, and no visible clotting was observed. No calcium replacement was needed. This pilot study suggests that it is possible to perform regional citrate anticoagulation without the need for separate calcium infusion during CRRT.

No MeSH data available.


Related in: MedlinePlus