Regional citrate anticoagulation in CVVH : A new protocol combining citrate solution with a phosphate‐containing replacement fluid
Open Access
- 7 August 2012
- journal article
- Published by Wiley in Hemodialysis International
- Vol. 17 (2), 313-320
- https://doi.org/10.1111/j.1542-4758.2012.00730.x
Abstract
Regional citrate anticoagulation (RCA) is a valid anticoagulation method in continuous renal replacement therapies (CRRT) and different combination of citrate and CRRT solutions can affect acid-base balance. Regardless of the anticoagulation protocol, hypophosphatemia occurs frequently in CRRT. In this case report, we evaluated safety and effects on acid-base balance of a new RCA- continuous veno-venous hemofiltration (CVVH) protocol using an 18mmol/L citrate solution combined with a phosphate-containing replacement fluid. In our center, RCA-CVVH is routinely performed with a 12mmol/L citrate solution and a postdilution replacement fluid with bicarbonate (protocol A). In case of persistent acidosis, not related to citrate accumulation, bicarbonate infusion is scheduled. In order to optimize buffers balance, a new protocol has been designed using recently introduced solutions: 18mmol/L citrate solution, phosphate-containing postdilution replacement fluid with bicarbonate (protocol B). In a cardiac surgery patient with acute kidney injury, acid-base status and electrolytes have been evaluated comparing protocol A (five circuits, 301hours) vs. protocol B (two circuits, 97hours): pH7.39 +/- 0.03 vs. 7.44 +/- 0.03 (P<0.0001), bicarbonate 22.3 +/- 1.8 vs. 22.6 +/- 1.4mmol/L (NS), Base excess 2.8 +/- 2.1 vs. 1.6 +/- 1.2 (P=0.007), phosphate 0.85 +/- 0.2 vs. 1.3 +/- 0.5mmol/L (P=0.027). Protocol A required bicarbonate and sodium phosphate infusion (8.9 +/- 2.8mmol/h and 5g/day, respectively) while protocol B allowed to stop both supplementations. In comparison to protocol A, protocol B allowed to adequately control acid-base status without additional bicarbonate infusion and in absence of alkalosis, despite the use of a standard bicarbonate concentration replacement solution. Furthermore, the combination of a phosphate-containing replacement fluid appeared effective to prevent hypophosphatemiaKeywords
This publication has 29 references indexed in Scilit:
- Regional citrate anticoagulation in cardiac surgery patients at high risk of bleeding: a continuous veno-venous hemofiltration protocol with a low concentration citrate solutionCritical Care, 2012
- Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patientsCritical Care, 2012
- Continuous Renal Replacement Therapy: Cause and Treatment of Electrolyte ComplicationsSeminars in Dialysis, 2010
- Phosphate-containing dialysis solution prevents hypophosphatemia during continuous renal replacement therapyActa Anaesthesiologica Scandinavica, 2010
- Continuous renal replacement therapy: recent advances and future researchNature Reviews Nephrology, 2010
- Clinical review: Anticoagulation for continuous renal replacement therapy - heparin or citrate?Critical Care, 2010
- Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unitClinical Kidney Journal, 2009
- Citrate pharmacokinetics and calcium levels during high-flux dialysis with regional citrate anticoagulationNephrology Dialysis Transplantation, 2009
- Hypophosphatemia and phosphate supplementation during continuous renal replacement therapy in childrenKidney International, 2009
- Intensity of Renal Support in Critically Ill Patients with Acute Kidney InjuryThe New England Journal of Medicine, 2008