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Increased total to ionized calcium ratio during continuous venovenous hemodialysis with regional citrate

H U Meier-Kriesche1, J Gitomer, K Finkel

  • 1Division of Renal Disease and Hypertension, The University of Texas Medical School at Houston, TX, USA.

Critical Care Medicine
|May 25, 2001
PubMed

Insights

An elevated total to ionized calcium ratio is common in patients on citrate anticoagulation for continuous venovenous hemodialysis (CVVHD). This ratio indicates citrate accumulation, especially in liver failure patients, and is linked to higher mortality.

Area of Science:

  • Nephrology
  • Critical Care Medicine
  • Clinical Chemistry

Background:

  • Citrate anticoagulation is a standard for continuous venovenous hemodialysis (CVVHD) to prevent bleeding.
  • Previous observations noted elevated total to ionized calcium ratios in liver failure patients on CVVHD, suggesting impaired citrate metabolism.

Purpose of the Study:

  • To determine the incidence and clinical significance of elevated total to ionized calcium ratios during citrate-based CVVHD.
  • To compare patients with elevated ratios to control groups with and without liver failure.

Main Methods:

  • 161 patients undergoing citrate-based CVVHD were screened for elevated total to ionized calcium ratios.
  • Patients with elevated ratios (study group) were compared to two control groups: those without liver failure and those with liver failure but normal ratios.

Main Results:

  • An elevated total to ionized calcium ratio was found in 12% of all patients, and 33% of liver failure patients.
  • The study group showed higher total calcium, lower ionized calcium, and higher total to ionized calcium ratios, requiring increased calcium chloride replacement.
  • Elevated ratios were associated with increased mortality, though no complications from hypocalcemia or hypercalcemia occurred.

Conclusions:

  • Systemic citrate accumulation, indicated by elevated total to ionized calcium ratios, is common in CVVHD patients using citrate.
  • Monitoring this ratio aids in early detection of liver failure patients with impaired citrate metabolism, necessitating higher calcium chloride infusion rates.
Abstract

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