title: Regional citrate anticoagulation for continuous venovenous hemodiafiltration using calcium-containing dialysate.
abstract: BACKGROUND
  Regional anticoagulation with trisodium citrate for continuous venovenous hemodiafiltration (CVVHDF) is an effective and safe alternative to heparin, especially in patients at high risk for bleeding. However, regional citrate anticoagulation is not used widely because current protocols are complex, labor intensive, and cumbersome. Existing protocols require the use of calcium-free dialysate with a continuous systemic calcium infusion to prevent hypocalcemia. We evaluated Anticoagulant Citrate Dextrose Formula A (ACD-A) solution for regional anticoagulation in CVVHDF in combination with a commercially available calcium-containing dialysis solution.
  
  
  METHODS
  Thirty-eight patients in the intensive care units underwent citrate-based CVVHDF using low-calcium peritoneal dialysis solution (calcium, 5.0 mg/dL [1.25 mmol/L]). ACD-A infusion rate was adjusted to maintain postfilter ionized calcium (iCa++) levels at 1.0 to 2.0 mg/dL (0.25 to 0.5 mmol/L). Calcium chloride (10%) solution was administered intravenously every 6 hours on an as-needed basis to maintain systemic serum iCa++ levels at 3.5 to 4.0 mg/dL (0.88 to 1.0 mmol/L).
  
  
  RESULTS
  CVVHDF was performed for a total of 394 days using 149 hemofilters. Mean hemofilter life span was 63.5 +/- 27.1 hours. Seventy-five percent, 61%, and 49% of hemofilters were patent at 24, 48, and 72 hours, respectively. No patient experienced a change in clinical status caused by hypocalcemia and/or signs and symptoms of citrate toxicity. Four patients developed metabolic alkalosis requiring 0.1 N of hydrochloric acid infusion.
  
  
  CONCLUSIONS
  Our simplified technique of regional citrate anticoagulation for CVVHDF using calcium-containing dialysate is not associated with increased hemofilter clotting and obviates the need for a continuous systemic calcium infusion and calcium-free dialysate.
authors.affiliation: Department of Medicine, Division of Nephrology, State University of New York at Stony Brook, Stony Brook, NY 11794, USA.
authors.forename: Monika
authors.initials: M
authors.lastname: Gupta
authors.forename: Nand K
authors.initials: NK
authors.lastname: Wadhwa
authors.forename: Rose
authors.initials: R
authors.lastname: Bukovsky
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001774:Blood Chemical Analysis; D002118:Calcium / Q000008:administration & dosage; D002951:Citrates / Q000009:adverse effects / Q000627:therapeutic use*; D015314:Dialysis Solutions; D005260:Female; D006440:Hemofiltration / Q000009:adverse effects*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D000077559:Sodium Citrate
chemical_list: D000925:Anticoagulants; D002951:Citrates; D015314:Dialysis Solutions; D000077559:Sodium Citrate; D002118:Calcium