Metabolic complications during regional citrate anticoagulation in continuous venovenous hemodialysis: single-center experience.
BACKGROUND
Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients at a high risk of bleeding. In a prospective, observational study we compared an established regional citrate anticoagulation protocol [Mehta R et al: Kidney Int 1990;38:976-981] versus a standard heparin anticoagulation protocol focusing on acid-base and electrolyte derangements as well as on cost effectiveness.


RESULTS
209 patients were included in the study. In 37 patients, citrate was used as the sole anticoagulant, 87 patients received low-dose heparin plus citrate, and 85 patients received only heparin as anticoagulant. A customized dialysate solution was used for citrate-anticoagulated CRRT (no buffer, no calcium, reduced sodium concentration). Filter life was significantly higher during citrate anticoagulation compared to heparin anticoagulation (80.2 +/- 60 vs. 30.2 +/- 32 h; p < 0.001). No difference was found between citrate and citrate-heparin anticoagulation (p = 0.310). Metabolic alkalosis was observed in more than 50% of patients on citrate anticoagulation. Alkalosis developed within the first 72 h after initiating treatment and could be reversed in almost all cases by increasing the dialysate flow rate. Hypercalcemia was observed in 13 patients on citrate anticoagulation. Patients with impaired liver function were particularly at risk. Systemic hypocalcemia, hypernatremia, and anion gap acidosis were not observed. Citrate anticoagulation was well tolerated hemodynamically. A longer filter life during citrate anticoagulation translated into a significant cost reduction compared to standard heparin anticoagulation (p < 0.01).


CONCLUSIONS
Regional anticoagulation with trisodium citrate in combination with a customized calcium-free dialysate is a safe and effective alternative to a heparin-based anticoagulation regimen.
Department of Nephrology, Charité, Humboldt University of Berlin, Germany. stanislao.morgera@charite.de
Stanislao
S
Morgera
Cornelia
C
Scholle
Gitana
G
Voss
Michael
M
Haase
Ortrud
O
Vargas-Hein
Dietmar
D
Krausch
Christoph
C
Melzer
Simone
S
Rosseau
Heidrun
H
Zuckermann-Becker
Hans-H
HH
Neumayer
D000137:Acid-Base Imbalance / Q000139:chemically induced; D058186:Acute Kidney Injury / Q000628:therapy; D000368:Aged; D000369:Aged, 80 and over; D000471:Alkalosis / Q000139:chemically induced*; D000925:Anticoagulants / Q000009:adverse effects* / Q000191:economics / Q000627:therapeutic use; D001639:Bicarbonates / Q000097:blood; D002118:Calcium; D002614:Chelating Agents / Q000009:adverse effects / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use; D002951:Citrates / Q000009:adverse effects* / Q000191:economics / Q000493:pharmacokinetics / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D015312:Hemodialysis Solutions / Q000009:adverse effects* / Q000737:chemistry / Q000191:economics; D006493:Heparin / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D006934:Hypercalcemia / Q000139:chemically induced*; D008099:Liver / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D000077559:Sodium Citrate; D013927:Thrombosis / Q000517:prevention & control
D000925:Anticoagulants; D001639:Bicarbonates; D002614:Chelating Agents; D002951:Citrates; D015312:Hemodialysis Solutions; D000077559:Sodium Citrate; D006493:Heparin; D002118:Calcium