title: Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment.
abstract: OBJECTIVE
  A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.
  
  
  METHODS
  All patients treated with SLED (8- to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.
  
  
  RESULTS
  This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (< 3.6 mg/dl or < 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).
  
  
  CONCLUSIONS
  This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.
authors.affiliation: Acute and Chronic Renal Failure Unit,, †1 ICU,, ‡2 ICU,, §Heart Surgery ICU, and, *Kidney-Pancreas Transplant Unit, Parma University Hospital, Parma, Italy;, ‖Nephrology and Transplantation Unit, Bary University Hospital, Bari, Italy;, ¶Nephrology and Dialysis Unit, Rome University Hospital, Roma, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Fiaccadori
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Regolisti
authors.forename: Carola
authors.initials: C
authors.lastname: Cademartiri
authors.forename: Aderville
authors.initials: A
authors.lastname: Cabassi
authors.forename: Edoardo
authors.initials: E
authors.lastname: Picetti
authors.forename: Maria
authors.initials: M
authors.lastname: Barbagallo
authors.forename: Tiziano
authors.initials: T
authors.lastname: Gherli
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Castellano
authors.forename: Santo
authors.initials: S
authors.lastname: Morabito
authors.forename: Umberto
authors.initials: U
authors.lastname: Maggiore
mesh_terms: D058186:Acute Kidney Injury / Q000628:therapy*; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D019343:Citric Acid / Q000097:blood / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000009:adverse effects / Q000295:instrumentation*
chemical_list: D000925:Anticoagulants; D019343:Citric Acid