title: Citrate anticoagulation during post-dilution hemodiafiltration with a high cut-off (Theralite) membrane.
abstract: Citrate anticoagulation has not yet been described for hemodiafiltration (HDF) with high cut-off (HCO) membranes, which can be used in the treatment of cast nephropathy secondary to multiple myeloma. A 57-year-old male patient with multiple myeloma and acute renal failure was treated with HDF using a HCO membrane (Theralite) each or every other day. Due to thrombocytopenia, citrate anticoagulation was done for the first 7 h, and anticoagulant-free HDF was performed for the last hour to avoid citrate accumulation. Magnesium, phosphate, and albumin were measured after 3, 6, and 8 h, and were replaced as necessary. Thirty-two post-dilution HDF procedures (8 h each, infusate 24 L) were performed with blood flow at 300-330 mL/h; sodium citrate 4% was infused at 300 mL/h and 1 mol/L calcium chloride was infused at a mean rate of 14.6 ± 1.1 mL/h. Calcium-free dialysate/infusate was used. Ionized calcium was stable (1.10 ± 0.06 before and 1.08 ± 0.06 mmol/L after HDF). Magnesium was stable (0.67 ± 0.12 before and 0.68 ± 0.05 mmol/L after HDF), with an average 390 ± 180 mg per procedure, substituted orally. There was no metabolic alkalosis or hypernatremia after the procedures, and no significant clotting was noted. The total/ionized calcium ratio (1.87 ± 0.22 before vs. 1.56 ± 0.20 after 6 h) and the corrected/ionized calcium ratio (2.02 ± 0.21 before vs. 1.88 ± 0.27 after 6 h) decreased during HDF, indicating no citrate accumulation. Citrate anticoagulation was effectively performed during 8 h of HCO membrane HDF. There were no side effects of citrate anticoagulation, nor were any signs of citrate accumulation noted.
authors.affiliation: Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia. janko.kovac@kclj.si
authors.forename: Janko
authors.initials: J
authors.lastname: Kovač
authors.forename: Jakob
authors.initials: J
authors.lastname: Gubenšek
authors.forename: Andreja Marn
authors.initials: AM
authors.lastname: Pernat
authors.forename: Jadranka
authors.initials: J
authors.lastname: Buturović-Ponikvar
authors.forename: Boštjan
authors.initials: B
authors.lastname: Kersnič
authors.forename: Jože
authors.initials: J
authors.lastname: Pretnar
authors.forename: Rafael
authors.initials: R
authors.lastname: Ponikvar
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology / Q000628:therapy; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D002951:Citrates / Q000009:adverse effects / Q000627:therapeutic use*; D017583:Hemodiafiltration / Q000379:methods*; D006801:Humans; D008297:Male; D008567:Membranes, Artificial; D008875:Middle Aged; D009101:Multiple Myeloma / Q000150:complications; D000077559:Sodium Citrate; D013921:Thrombocytopenia / Q000209:etiology
chemical_list: D000925:Anticoagulants; D002951:Citrates; D008567:Membranes, Artificial; D000077559:Sodium Citrate