title: A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges.
abstract: Regional citrate anticoagulation (RCA) is proposed for various extracorporeal purification techniques to overcome the risk of bleeding that might result from systemic anticoagulation. Yet, no individualized treatment protocol has been proposed for therapeutic plasma exchange (TPE) so far. The objective of this study was to assess the determinants of blood citrate concentration needed and to develop an individualized RCA protocol useful for clinical practice.
  
  
  
  The study population included 14 patients who underwent a total of 47 TPE sessions. Citrate was infused pre-plasmafilter. Post-plasmafilter and systemic plasma ionized calcium concentrations were measured at standardized time intervals. An algorithm was proposed for the supplementation of calcium. During the discovery phase, citrate was infused at a fixed starting rate, and adapted accordingly to obtained post-plasmafilter ionized calcium levels. Using a mathematical approach, an algorithm was thereafter developed for individualized prescriptions of citrate.
  
  
  
  Pre-treatment values of hematocrit and plasma ionized calcium were the main determinants of the required rate of citrate infusion. These can be integrated into a final equation enabling to individualize the prescription. A prefilter ionized calcium concentration between 0.24 and 0.33 mmol/l prevented coagulation of the extracorporeal circuit. Significant hypocalcemia occurred in 8.5% of treatments. There were no significant acid-base disturbances.
  
  
  
  We propose a new protocol, which enables for the first time to individualize the prescription of regional citrate anticoagulation during TPE, in an efficient manner. The immediately obtained regional anticoagulation protects against both the risk of coagulation of the membrane and the exposure to an excess of citrate.
authors.affiliation: Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France. sebastien.kissling@chuv.ch.|Biomécanique et Bioingénierie, Université de Technologie de Compiègne (UTC), UMR CNRS 7338, Compiègne, 60203, France. sebastien.kissling@chuv.ch.|Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland. sebastien.kissling@chuv.ch.
authors.forename: Sébastien
authors.identifier: 0000-0001-7682-3896
authors.initials: S
authors.lastname: Kissling
authors.affiliation: Biomécanique et Bioingénierie, Université de Technologie de Compiègne (UTC), UMR CNRS 7338, Compiègne, 60203, France.
authors.forename: Cécile
authors.initials: C
authors.lastname: Legallais
authors.affiliation: Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland.
authors.forename: Menno
authors.initials: M
authors.lastname: Pruijm
authors.affiliation: Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Teta
authors.affiliation: Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland.
authors.forename: Bruno
authors.initials: B
authors.lastname: Vogt
authors.affiliation: Service de Néphrologie et Hypertension, Centre Hospitalier Universitaire Vaudois (CHUV), Rte du Bugnon 17, 1011, Lausanne, CH, Switzerland.
authors.forename: Michel
authors.initials: M
authors.lastname: Burnier
authors.affiliation: Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Rondeau
authors.affiliation: Service d'Urgences néphrologiques et Transplantation rénale (UNTR), Hôpital Tenon, Paris, 75020, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Ridel
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D056648:Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis / Q000628:therapy*; D000925:Anticoagulants / Q000008:administration & dosage*; D002118:Calcium / Q000008:administration & dosage*; D019343:Citric Acid / Q000008:administration & dosage*; D002985:Clinical Protocols; D005260:Female; D006084:Graft Rejection / Q000628:therapy*; D006470:Hemorrhage / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010951:Plasma Exchange / Q000379:methods*; D057049:Thrombotic Microangiopathies / Q000628:therapy*
chemical_list: D000925:Anticoagulants; D019343:Citric Acid; D002118:Calcium
keywords: Citrate; Clinical protocol; Drug prescription; Mathematical model; Plasma exchanges