scholarly journals Regional citrate anticoagulation in patients with liver failure - time for a rethink?

Critical Care ◽  
2012 ◽  
Vol 16 (5) ◽  
pp. 153 ◽  
Author(s):  
Sameer Patel ◽  
Julia Wendon
Keyword(s):  
Liver Failure ◽  
Failure Time ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation

Safety and Efficacy of Regional Citrate Anticoagulation during Plasma Adsorption Plus Plasma Exchange Therapy for Patients with Acute-on-Chronic Liver Failure: A Pilot Study

2019 ◽  
Vol 48 (3) ◽  
pp. 223-232 ◽  
Author(s):  
Yuanji Ma ◽  
Fang Chen ◽  
Yan Xu ◽  
Ming Wang ◽  
Taoyou Zhou ◽  
...  
Keyword(s):  
Pilot Study ◽  
Liver Failure ◽  
Plasma Exchange ◽  
Chronic Liver ◽  
Regional Citrate Anticoagulation ◽  
Chronic Liver Failure ◽  
Safety And Efficacy ◽  
Citrate Anticoagulation ◽  
Citrate Accumulation ◽  
Heparin Anticoagulation

Background: Patients with acute-on-chronic liver failure (ACLF) might be at risk for citrate accumulation during plasma adsorption plus plasma exchange (PE) therapy with regional citrate anticoagulation (RCA). Objectives: To assess the safety and efficacy of RCA during double plasma molecular adsorption system (DPMAS) plus PE therapy for patients with ACLF. Method: A prospective nonrandomized controlled pilot study was conducted at West China Hospital of Sichuan University. Patients with ACLF were enrolled to heparin anticoagulation (HA) group and RCA group. Serial blood samples were taken. Patients were followed up for 3 months. Results: Twenty-four patients with 94 sessions of HA and 28 patients with 106 sessions of RCA were enrolled. RCA method did not affect the therapeutic efficacy, the function of extracorporeal circulation, and the prognosis of these patients. The occurrences of citrate accumulation in RCA group were 0.0, 67.0, 100.0, 34.0, and 0.0% before DPMAS therapy, at the end of DPMAS therapy, immediately after PE therapy, 2 h after PE therapy, and the next morning, while that in HA group were 0.0, 0.0, 100.0, 7.4, and 0.0%, respectively. The occurrences of citrate accumulation at the end of DPMAS therapy and at 2 h after PE therapy in RCA group were much higher than that in HA group (67.0 vs. 0.0%, p = 0.000; 34.0 vs. 7.4%, p = 0.000, respectively). Although the trend of citrate accumulation in RCA group was much more obvious than that in HA group during and after DPMAS plus PE therapy (p = 0.000), the values on the next morning were similar between the 2 groups (p > 0.05). The main alteration of acid–base status was metabolic alkalosis with no difference between the 2 groups. Conclusions: RCA might be safe and effective in patients with ACLF receiving plasma adsorption plus PE therapy. RCA method might offer an alternative anticoagulation method for them.

scholarly journals Regional Citrate Anticoagulation Protocol For Patients With Presumed Absent Citrate Metabolism

Kidney360 ◽  
2020 ◽  
pp. 10.34067/KID.0005342020
Author(s):  
Balazs Szamosfalvi ◽  
Vidhit Puri ◽  
Ryann Sohaney ◽  
Benjamin Wagner ◽  
Amy Riddle ◽  
...  
Keyword(s):  
Liver Failure ◽  
Mass Balance ◽  
Infusion Rate ◽  
Kidney Injury ◽  
Albumin Level ◽  
Regional Citrate Anticoagulation ◽  
Citrate Anticoagulation ◽  
Citrate Metabolism ◽  
Effluent Flow Rate ◽  
Citrate Toxicity

Background: Regional citrate anticoagulation (RCA) is not recommended in patients with shock or severe liver failure. We designed a protocol with personalized pre-calculated flow settings for patients with absent citrate metabolism that abrogates risk of citrate toxicity, maintains neutral CKRT circuit calcium mass balance and normal systemic ionized calcium levels. Methods: Single center prospective cohort study of patients in five Adult Intensive Care Units triaged to the CVVHDF-RCA "Shock" protocol. Results: Of 31 patients included in the study, 30 (97%) had acute kidney injury, 16 (52%) had acute liver failure, and 5 (16%) had cirrhosis at the start of CKRT. The median (interquartile range (IQR)) lactate was 5 (3.2 to 10.7), AST 822 (122 to 2950), ALT 352 (41 to 2238), total bilirubin 2.7 (1.0 to 5.1), INR 2 (1.5 to 2.6). The median first hemofilter life censored for causes other than clotting exceeded 70 hours. The cumulative incidence of hypernatremia (Na >148 mM), metabolic alkalosis (HCO3- >30 mM) and hypophosphatemia (P< 2 mg/dL) were 1/26 (4%), 0/30 (0%), 1/30 (3%) respectively and were not clinically significant. Mild hypocalcemia occurred in the first 4 hours in 2/31 patients and corrected by hour 6 with no additional Ca-supplementation beyond the per-protocol administered Ca-infusion. The maximum systemic total Ca (tCa; mM)/ionized Ca (iCa; mM) ratio never exceeded 2.5. Conclusions: The "Shock" protocol can be used without contra-indications and is effective in maintaining circuit patency with a high, fixed ACDA infusion rate to blood flow ratio. Keeping single-pass citrate extraction on the dialyzer >0.75 minimizes the risk of citrate toxicity even in patients with absent citrate metabolism. Pre-calculated, personalized dosing of the initial Ca-infusion rate from a table based on the patient's albumin level and the filter effluent flow rate maintains neutral CKRT circuit calcium mass balance and a normal systemic iCa level.

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