title: Regional citrate anticoagulation for PrismaFlex continuous renal replacement therapy.
abstract: BACKGROUND
  Since Mehta et al. reported the first successful use of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) in 1990, RCA is increasingly used for CRRT because it provides filter patency with minimal risk of bleeding. However, RCA has been associated with significant metabolic complications including hypocalcemia, hypernatremia, metabolic alkalosis, and citrate toxicity.
  
  
  OBJECTIVE
  To describe our experience with a newly implemented RCA protocol with acid citrate dextrose formula A (ACD-A) and intravenous calcium gluconate, for use with PrismaFlex CRRT in critically ill patients with acute kidney injury.
  
  
  METHODS
  A retrospective chart review was conducted from May 1, 2006, until May 1, 2007, in a 16-bed medical-surgical university-affiliated intensive care unit. Data collected included dialysis filter life, patient and circuit metabolic parameters, and units of packed red blood cells transfused.
  
  
  RESULTS
  Forty-eight patients received dialysis with citrate (n = 178 filters). Circuit clotting occurred in 24% of all filters. Mean +/- SD filter life was 38.4 +/- 25.9 hours, and filter survival at 48 hours was 38.2%. Persistent metabolic alkalosis while on CRRT was identified in 6 of 45 (13.3%) patients. Mild hypocalcemia (ionized calcium <3.6 mg/dL) occurred in 11 (23%) patients, but no patient had an ionized calcium level less than 2.8 mg/dL. Six patients, 3 with acute leukemia, required transfusion of 2 or more units of packed red blood cells in 24 hours.
  
  
  CONCLUSIONS
  We found that anticoagulation of PrismaFlex CRRT with ACD-A and intravenous calcium gluconate provided reasonable filter patency, but with minor metabolic complications. Close monitoring of electrolyte and acid-base balance is required to minimize metabolic derangements.
authors.affiliation: Department of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. lburry@mtsinai.on.ca
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Burry
authors.forename: David D
authors.initials: DD
authors.lastname: Tung
authors.forename: David
authors.initials: D
authors.lastname: Hallett
authors.forename: Toni
authors.initials: T
authors.lastname: Bailie
authors.forename: Virginia
authors.initials: V
authors.lastname: Carvalhana
authors.forename: David
authors.initials: D
authors.lastname: Lee
authors.forename: Steve
authors.initials: S
authors.lastname: Ramganesh
authors.forename: Robert
authors.initials: R
authors.lastname: Richardson
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Lapinsky
mesh_terms: D058186:Acute Kidney Injury / Q000628:therapy*; D000328:Adult; D000368:Aged; D000471:Alkalosis / Q000209:etiology; D000925:Anticoagulants / Q000008:administration & dosage*; D002125:Calcium Gluconate / Q000008:administration & dosage; D019343:Citric Acid / Q000008:administration & dosage*; D016638:Critical Illness; D005260:Female; D005947:Glucose / Q000008:administration & dosage / Q000031:analogs & derivatives*; D006785:Hospitals, University; D006801:Humans; D006996:Hypocalcemia / Q000209:etiology; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D017582:Renal Replacement Therapy / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants; C002113:acid citrate dextrose; D019343:Citric Acid; D005947:Glucose; D002125:Calcium Gluconate