Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge.
OBJECTIVE
Feasibility and safety evaluation of regional citrate anticoagulation (RCA) versus systemic heparinization for continuous venovenous hemodiafiltration.


METHODS
Combined retrospective and prospective observational study performed in a secondary multidisciplinary intensive care unit of the Ospedale Civico Lugano Switzerland.


METHODS
Twelve hemodynamically unstable patients (median APACHE II score 26, interquartile range 22-29) in whom heparin was judged to be at least temporarily contraindicated. A switch from RCA (predilution setting; same iso-osmotic replacement and dialysis fluid) to heparinization or vice versa was recommended for the final evaluation; 56 dialyzers were used for RCA (1,400 h) and 39 for heparinization (1,271 h).


RESULTS
Median dialyzer life span was 24.2 h (interquartile range 17.4-42.3) for RCA and 42.5 h (20.6-69.1) for heparinization. Fluid control and dialysis quality were similar in the two groups and required no additional intervention. The risk of significant hypocalcemia and metabolic alkalosis was higher at the beginning of the RCA program and decreased with the further training of the staff. Seven bleeding episodes occurred with heparinization vs. three in RCA.


CONCLUSIONS
RCA may be a safe and useful form of anticoagulation which is more expensive than heparinization but helps to minimize bleeding risk. The risk of metabolic complications is higher at the beginning of a new RCA program. For centers lacking experienced staff we suggest reserving this technique for patients with rapid clotting of the extracorporeal circuit if treated without anticoagulation.
Gabutti
Luca
L
Department of Internal Medicine, Ospedale la Carità Locarno, Locarno, Switzerland. lugabutti@swissonline.ch
Marone
Claudio
C
Colucci
Giuseppe
G
Duchini
Francesca
F
Schönholzer
Carlo
C
D018806:APACHE; D058186:Acute Kidney Injury / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000471:Alkalosis / Q000209:etiology; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D002951:Citrates / Q000008:administration & dosage* / Q000009:adverse effects; D000075202:Contraindications; D005240:Feasibility Studies; D005260:Female; D017583:Hemodiafiltration / Q000379:methods*; D006439:Hemodynamics; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D006996:Hypocalcemia / Q000209:etiology; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D012449:Safety; D013557:Switzerland
D000925:Anticoagulants; D002951:Citrates; D006493:Heparin