title: Regional citrate anticoagulation for continuous renal replacement therapy in the perioperative care of liver transplant recipients: a single center experience.
abstract: Kidney injury with concomitant hemodialysis is a common finding in perioperative care of liver transplant patients. The aim of this study was to evaluate disturbances in acid-base status, electrolyte balance and citrate accumulation during hemodialysis with regional citrate anticoagulation in perioperative care of liver transplant recipients. A retrospective, single center evaluation was conducted of patients with severe liver dysfunction receiving renal replacement therapy in the perioperative care of liver transplantation in a multidisciplinary ICU of a university hospital. Within 5 days of ICU stay, 89 patients undergoing liver transplantation received regional citrate anticoagulation for hemodialysis. During the study period pH (7.39 [7.33/7.43] vs. 7.44 [7.39/7.47], P-value = 0.014), base excess values (-0.9 [-5.08/2.35] vs. 4.3 [1.93/8.21], P-value = 0.001) and standard bicarbonate (23.6 [20/26.9] vs. 28.2 [26.2/32.2], P-value = 0.001) significantly increased, whereas lactate levels (2.6 [1.60/4.45] vs. 1.25 [0.98/1.9], P-value = 0.071) and Catot /Caion -ratio decreased or remained below the upper reference. Hypocalcemia appeared mostly within 48 h after dialysis initiation. Although sodium levels increased during the observation, rates of hypernatremia were comparable between hemodialysis days 1 and 5. Hemodialysis using regional citrate anticoagulation remains a challenge in the perioperative care of liver transplant recipients. Major attention must be paid to acid-base disturbances and citrate accumulation within 48 h after dialysis initiation. Nevertheless, regional citrate anticoagulation in liver dysfunction is a feasible and valuable tool, when limitations and pitfalls are adequately considered.
authors.affiliation: Department of Anaesthesiology and Critical Care Medicine, Visceral and Vascular Surgery, Jena, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Sponholz
authors.forename: Utz
authors.initials: U
authors.lastname: Settmacher
authors.forename: Michael
authors.initials: M
authors.lastname: Bauer
authors.forename: Andreas
authors.initials: A
authors.lastname: Kortgen
mesh_terms: D000136:Acid-Base Equilibrium; D058186:Acute Kidney Injury / Q000209:etiology / Q000628:therapy*; D000925:Anticoagulants / Q000008:administration & dosage*; D019343:Citric Acid / Q000008:administration & dosage*; D015331:Cohort Studies; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D006785:Hospitals, University; D006801:Humans; D007362:Intensive Care Units; D007677:Kidney Function Tests; D017093:Liver Failure / Q000175:diagnosis / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods; D011379:Prognosis; D006435:Renal Dialysis / Q000379:methods*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D019343:Citric Acid
keywords: Acid-base status; Citrate anticoagulation; Electrolyte balance; Hemodialysis; Intensive care; Liver failure