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Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions
Olivier Cointault1, Nassim Kamar, Pierre Bories
1Department of Nephrology, Dialysis and Transplantation, CHU Toulouse-Rangueil, TSA 50032, 31059 Toulouse Cedex 9, France.
Insights
Regional citrate anticoagulation effectively prevents clotting during continuous venovenous haemodiafiltration (CVVHDF) in critically ill patients. This method offers an alternative to heparin but incurs higher costs, making it suitable for those with high bleeding risks.
Area of Science:
- Nephrology
- Critical Care Medicine
- Biochemistry
Background:
- Regional citrate anticoagulation is an effective method for anticoagulation during continuous renal replacement therapy (CRRT).
- This study evaluates the efficacy, safety, and cost of a regional citrate anticoagulation protocol using commercial solutions in critically ill patients undergoing continuous venovenous haemodiafiltration (CVVHDF).
Purpose of the Study:
- To assess the efficacy and safety of regional citrate anticoagulation for CVVHDF.
- To determine the cost-effectiveness of this citrate protocol compared to traditional anticoagulation methods.
Main Methods:
- A citrate solution (112.9 mmol/l disodium citrate) was administered pre-filter at a median rate of 260 ml/h.
- Post-filtered ionized calcium was maintained between 0.25-0.4 mmol/l, with plasma calcium >1.1 mmol/l maintained via calcium chloride infusion.
- Dialysate and replacement solutions were delivered at 1200 ml/h, with biological parameters monitored every 6 hours over 48-hour sessions.
Main Results:
- Mean dialyser survival was 39 +/- 11 hours, with 18% experiencing dialyser clotting.
- No bleeding events or significant modifications in coagulation parameters were observed.
- The citrate protocol incurred an additional cost of 25 euro/day compared to heparin anticoagulation.
Conclusions:
- An efficient regional citrate anticoagulation method for CVVHDF using commercial solutions was developed.
- Patient monitoring intensity was comparable to heparin anticoagulation.
- Due to higher costs, this citrate protocol is recommended primarily for patients at high risk of bleeding.
Background:
Treatment with trisodium citrate provides an effective means of regional anticoagulation during continuous renal replacement therapy (CRRT). We evaluated the efficacy, safety and cost of a regional citrate anticoagulation protocol using commercial solutions in 17 critically ill patients treated with continuous venovenous haemodiafiltration (CVVHDF). We performed a total of 22 sessions.
Methods:
We delivered an A.C.D-A(541(R)) solution containing 112.9 mmol/l disodium citrate (3.22%) at a median rate of 260 (190-280) ml/h via the pre-filter port of a COBE PRISMA with an AN-69 dialyser, while adjusting the rate to maintain post-filtered ionized calcium (iCa(2+)) between 0.25 and 0.4 mmol/l. Plasma iCa(2+) was maintained at >1.1 mmol/l by infusion of calcium chloride at a median rate of 1.70 (1.36-2.27) mmol/h. The dialysate was easily modified according to the acid-base status of each patient. Both replacement and dialysate solutions were delivered at 1200 ml/h. Each session was scheduled for 48 h and biological parameters were assessed every 6 h.
Results:
The mean dialyser survival was 39 +/- 11 h (median 41.5 h; range 13-48 h). We observed dialyser clotting in four cases (18%). There were no bleeding events or modifications of coagulation parameters. The citrate solution, replacement solution and dialysate were obtained as commercial products. Both the replacement and dialysate solutions contained calcium. The extra cost of this technique was 25 euro;/day as compared to anticoagulation with heparin.
Conclusions:
We designed an efficient method of regional citrate anticoagulation for CVVHDF by using commercial solutions. The monitoring of patients was as intensive as during heparin anticoagulation for CRRT. Because of the higher cost of this method, it should be proposed only for patients with high bleeding risk.