title: Continuous venovenous haemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency: a prospective observational study.
abstract: BACKGROUND
  There is ongoing controversy concerning optimum anticoagulation and buffering in continuous venovenous haemofiltration (CVVH). Regional anticoagulation with trisodium citrate also acting as a buffer in the replacement fluid has several advantages and disadvantages over prefilter citrate administration alone. We analysed a large cohort of patients with acute kidney injury (AKI) treated by the former method and hypothesized that it is safe and efficacious.
  
  
  METHODS
  Patients admitted at the intensive care unit with AKI and a high bleeding risk, without exclusion of liver disease, treated by CVVH with citrate in a custom-made replacement solution were prospectively included. Patient and CVVH characteristics, including citrate accumulation, were evaluated in outcome groups. A standardized mortality rate (SMR) was calculated using the simplified acute physiology score II.
  
  
  RESULTS
  Ninety-seven patients were included; metabolic control was adequate and did not differ between outcome groups, apart from lower pH/bicarbonate in non-survivors. Citrate accumulation was proven in 9% and was timely identified. These patients had about threefold higher plasma transaminases and higher CVVH dose and mortality. The hospital mortality was 60% with a SMR of 1.1 (95% confidence interval 0.90-1.40): age and hyperlactatemia, rather than CVVH-characteristics and citrate accumulation, predicted mortality in multivariable analysis.
  
  
  CONCLUSIONS
  In critically ill, patients with AKI at high risk of bleeding, CVVH with citrate-containing replacement solution is safe and efficacious. The risk for citrate accumulation is 9% and best predicted by levels of transaminases. It carries, when citrate is discontinued, no attributable mortality.
authors.affiliation: Departments of Nephrology, VU University Medical Centre, Amsterdam, The Netherlands. SA.Nurmohamed@vumc.nl
authors.forename: Shaikh A
authors.initials: SA
authors.lastname: Nurmohamed
authors.forename: Borefore P
authors.initials: BP
authors.lastname: Jallah
authors.forename: Marc G
authors.initials: MG
authors.lastname: Vervloet
authors.forename: Gul
authors.initials: G
authors.lastname: Yldirim
authors.forename: Pieter M
authors.initials: PM
authors.lastname: ter Wee
authors.forename: A B Johan
authors.initials: AB
authors.lastname: Groeneveld
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002951:Citrates / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D015312:Hemodialysis Solutions / Q000008:administration & dosage* / Q000009:adverse effects; D006440:Hemofiltration / Q000009:adverse effects / Q000379:methods*; D006470:Hemorrhage / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D002951:Citrates; D015312:Hemodialysis Solutions; C514290:trisodium citrate