Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions.
BACKGROUND
Treatment with trisodium citrate provides an effective means of regional anticoagulation during continuous renal replacement therapy (CRRT). We evaluated the efficacy, safety and cost of a regional citrate anticoagulation protocol using commercial solutions in 17 critically ill patients treated with continuous venovenous haemodiafiltration (CVVHDF). We performed a total of 22 sessions.


METHODS
We delivered an A.C.D-A(541(R)) solution containing 112.9 mmol/l disodium citrate (3.22%) at a median rate of 260 (190-280) ml/h via the pre-filter port of a COBE PRISMA with an AN-69 dialyser, while adjusting the rate to maintain post-filtered ionized calcium (iCa(2+)) between 0.25 and 0.4 mmol/l. Plasma iCa(2+) was maintained at >1.1 mmol/l by infusion of calcium chloride at a median rate of 1.70 (1.36-2.27) mmol/h. The dialysate was easily modified according to the acid-base status of each patient. Both replacement and dialysate solutions were delivered at 1200 ml/h. Each session was scheduled for 48 h and biological parameters were assessed every 6 h.


RESULTS
The mean dialyser survival was 39 +/- 11 h (median 41.5 h; range 13-48 h). We observed dialyser clotting in four cases (18%). There were no bleeding events or modifications of coagulation parameters. The citrate solution, replacement solution and dialysate were obtained as commercial products. Both the replacement and dialysate solutions contained calcium. The extra cost of this technique was 25 euro;/day as compared to anticoagulation with heparin.


CONCLUSIONS
We designed an efficient method of regional citrate anticoagulation for CVVHDF by using commercial solutions. The monitoring of patients was as intensive as during heparin anticoagulation for CRRT. Because of the higher cost of this method, it should be proposed only for patients with high bleeding risk.
Cointault
Olivier
O
Department of Nephrology, Dialysis and Transplantation, CHU Toulouse-Rangueil, TSA 50032, 31059 Toulouse Cedex 9, France.
Kamar
Nassim
N
Bories
Pierre
P
Lavayssiere
Laurence
L
Angles
Olivier
O
Rostaing
Lionel
L
Genestal
Michèle
M
Durand
Dominique
D
D058186:Acute Kidney Injury / Q000628:therapy; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000494:pharmacology*; D001777:Blood Coagulation / Q000187:drug effects*; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000517:prevention & control; D002118:Calcium / Q000494:pharmacology; D002413:Cations, Divalent / Q000494:pharmacology; D002951:Citrates / Q000494:pharmacology*; D003365:Costs and Cost Analysis; D016638:Critical Illness; D015314:Dialysis Solutions / Q000494:pharmacology*; D005240:Feasibility Studies; D005260:Female; D017583:Hemodiafiltration / Q000009:adverse effects / Q000379:methods*; D006440:Hemofiltration / Q000009:adverse effects / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D000077559:Sodium Citrate; D016896:Treatment Outcome
D000925:Anticoagulants; D002413:Cations, Divalent; D002951:Citrates; D015314:Dialysis Solutions; D000077559:Sodium Citrate; D002118:Calcium