title: Continuous veno-venous hemofiltration using a phosphate-containing replacement fluid in the setting of regional citrate anticoagulation.
abstract: OBJECTIVE
  The need for prolonged anticoagulation and the occurrence of hypophosphatemia are well known drawbacks of continuous renal replacement therapies (CRRT). The aim was to evaluate the effects on acid-base status and serum phosphate of a regional citrate anticoagulation (RCA) protocol for continuous veno-venous hemofiltration (CVVH) combining the use of citrate with a phosphate-containing replacement fluid.
  
  
  METHODS
  In a small cohort of heart surgery patients undergoing CRRT for acute kidney injury, we adopted an RCA-CVVH protocol based on a commercially available citrate solution (18 mmol/l) combined with a recently introduced phosphate-containing replacement fluid (HCO3 -30 mmol/l, phosphate 1.2), aimed at preventing phosphate depletion.
  
  
  RESULTS
  In 10 high bleeding-risk patients, the RCA-CVVH protocol provided an adequate circuit lifetime (46.8 ± 30.3 h) despite the adoption of a low citrate dose and a higher than usual target circuit Ca2+ (≤0.5 mmol/l). Acid-base status was adequately maintained without the need for additional interventions on RCA-CVVH parameters and without indirect sign of citrate accumulation [(pH 7.43 (7.41-7.47), bicarbonate 24.4 mmol/l (23.2-25.6), BE 0 (-1.5 to 1.1), calcium ratio 1.97 (1.82-2.01); median (IQR)]. Serum phosphate was steadily maintained in a narrow range throughout RCA-CVVH days [1.1 mmol/l (0.9-1.4)]. A low amount of phosphorus supplementation (0.9 ± 2 g/day) was required in only 30% of patients.
  
  
  CONCLUSIONS
  Although needing further evaluation, the proposed RCA-CVVH protocol ensured a safe and effective RCA without electrolyte and/or acid-base derangements. CRRT-induced hypophosphatemia was prevented in most of the patients by the adoption of a phosphate-containing replacement solution, minimizing phosphate supplementation needs.
authors.affiliation: Department of Nephrology and Urology, Hemodialysis Unit, Umberto I, Policlinico di Roma, "Sapienza" University, Rome - Italy.
authors.forename: Santo
authors.initials: S
authors.lastname: Morabito
authors.forename: Valentina
authors.initials: V
authors.lastname: Pistolesi
authors.forename: Luigi
authors.initials: L
authors.lastname: Tritapepe
authors.forename: Elio
authors.initials: E
authors.lastname: Vitaliano
authors.forename: Laura
authors.initials: L
authors.lastname: Zeppilli
authors.forename: Francesca
authors.initials: F
authors.lastname: Polistena
authors.forename: Enrico
authors.initials: E
authors.lastname: Fiaccadori
authors.forename: Alessandro
authors.initials: A
authors.lastname: Pierucci
mesh_terms: D000136:Acid-Base Equilibrium / Q000187:drug effects; D058186:Acute Kidney Injury / Q000097:blood / Q000209:etiology / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects; D006348:Cardiac Surgical Procedures; D002951:Citrates / Q000009:adverse effects / Q000627:therapeutic use*; D015314:Dialysis Solutions / Q000009:adverse effects / Q000627:therapeutic use*; D006440:Hemofiltration / Q000009:adverse effects / Q000379:methods*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D017674:Hypophosphatemia / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D008875:Middle Aged; D010710:Phosphates / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use*; D013927:Thrombosis / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D002951:Citrates; D015314:Dialysis Solutions; D010710:Phosphates