title: Sustained low-efficiency dialysis with regional citrate anticoagulation in medical intensive care unit patients with liver failure: A prospective study.
abstract: OBJECTIVE
  Patients with liver failure requiring dialysis are at increased risk for citrate accumulation during sustained low-efficiency dialysis (SLED). The aim of this study was to evaluate the feasibilty of citrate SLED in critical ill patients with liver failure and investigate predictive parameters regarding citrate accumulation.
  
  
  METHODS
  This is a prospective study in 24 medical intensive care unit patients with liver failure and a total of 43 SLED runs (maximum of 3 runs per patient) using citrate anticoagulation. Liver function was characterized before SLED using not only laboratory parameters but also determination of the plasma disappearance rate of indocyanine green. In addition, blood gas parameters as well total calcium and citrate in serum were measured at baseline and defined time points during SLED.
  
  
  RESULTS
  Accumulation of citrate could be observed in all SLED runs, which were nearly normalized until the end of SLED and 24 hours after SLED, respectively. However, the critical threshold of total calcium/ionized calcium on ratio of greater than 2.5 was exceeded in only 1 patient. Equalization of initial metabolic acidosis was possible without major disturbances of acid base and electrolyte status. Liver function parameters showed poor predicitve capabilities regarding citrate accumulation.
  
  
  CONCLUSIONS
  Despite substantial accumulation of citrate in serum, SLED is save and feasible in patients with liver failure using a citrate anticoagulation. Careful monitoring of electrolytes and acid base status is mandatory to ensure patient safety.
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany. Electronic address: tobiaslahmer@me.com.
authors.forename: Tobias
authors.initials: T
authors.lastname: Lahmer
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Marlena
authors.initials: M
authors.lastname: Messer
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Rasch
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Analena
authors.initials: A
authors.lastname: Beitz
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Christopher
authors.initials: C
authors.lastname: Schnappauf
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Roland M
authors.initials: RM
authors.lastname: Schmid
authors.affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Huber
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage* / Q000378:metabolism; D002118:Calcium / Q000378:metabolism; D065096:Calcium Chelating Agents / Q000008:administration & dosage* / Q000378:metabolism; D019343:Citric Acid / Q000008:administration & dosage* / Q000378:metabolism; D004573:Electrolytes / Q000378:metabolism; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008103:Liver Cirrhosis / Q000628:therapy*; D017114:Liver Failure, Acute / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000379:methods*
chemical_list: D000925:Anticoagulants; D065096:Calcium Chelating Agents; D004573:Electrolytes; D019343:Citric Acid; D002118:Calcium
keywords: Citrate anticoagulation; Critical care; Liver failure; SLED