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A continuous veno-venous hemofiltration protocol with anticoagulant citrate dextrose formula A and a
Song C Ong1, Keith M Wille, Rajesh Speer
11 Department of Medicine, University of Alabama at Birmingham, Birmingham, AL - USA.
Insights
Regional citrate anticoagulation (RCA) with anticoagulant citrate dextrose formula-A (ACD-A) and calcium-containing dialysate effectively prevented filter clotting in continuous renal replacement therapy (CRRT). This method avoids systemic calcium infusion, addressing shortages of intravenous calcium.
Area of Science:
- Nephrology
- Critical Care Medicine
- Biochemistry
Background:
- Regional citrate anticoagulation (RCA) is crucial for continuous renal replacement therapy (CRRT).
- Systemic calcium infusion is typically required to counteract calcium loss during RCA.
- Intravenous calcium shortages in the US limit the use of RCA.
Purpose of the Study:
- To describe a novel continuous veno-venous hemofiltration (CVVH) protocol using RCA.
- To evaluate the efficacy of a protocol using anticoagulant citrate dextrose formula-A (ACD-A) and calcium-containing dialysate as post-filter replacement fluid (RF).
- To assess if this protocol can eliminate the need for systemic calcium infusion during CRRT.
Main Methods:
- A prospective study evaluated five CRRT patients experiencing frequent filter clotting.
- Patients were switched to CVVH utilizing ACD-A pre-blood pump, targeting post-filter ionized calcium (iCa2+) <0.5 mmol/l.
- Calcium-containing dialysate (1.5 mmol/l) was administered as post-filter RF.
Main Results:
- The protocol successfully maintained target post-filter iCa2+ (0.27-0.36 mmol/l) and patient iCa2+ (0.81-1.24 mmol/l).
- Mean filter survival significantly improved from 7 hours (without anticoagulation) to 42.6 hours with ACD-A (p<0.0001).
- The protocol demonstrated effective CRRT without requiring continuous systemic calcium infusion.
Conclusions:
- CVVH with ACD-A for RCA and calcium-containing RF is safe and effective.
- This protocol offers a viable alternative to systemic calcium infusion during CRRT.
- It presents a promising solution for maintaining CRRT during intravenous calcium shortages.
Introduction:
Regional citrate anticoagulation (RCA) is used as an anticoagulant for continuous renal replacement therapy (CRRT). A systemic calcium (Ca2+) infusion is required to replace Ca2+ lost in the effluent. The shortage of intravenous Ca2+ in the United States has limited RCA use. We describe a continuous veno-venous hemofiltration (CVVH) protocol with RCA using 2.2% anticoagulant citrate dextrose formula-A (ACD-A) and a commercial dialysate containing Ca2+ 1.5 mmol/l (N × Stage) as post-filter replacement fluid (RF), without need for Ca2+ infusion.
Methods:
We prospectively evaluated five patients on CRRT who had at least three episodes of filter clotting within 24 h. Patients were switched to CVVH using ACD-A infused pre-blood pump and titrated to achieve a post-filter ionized calcium (iCa2+) level <0.5 mmol/l. The Ca2+ -containing dialysate was delivered post-filter as RF.
Results:
Steady state mean serum chemistries were: Na+: 140.8 ± 2.3 meq/l, K+: 4.2 ± 0.4 meq/l, HCO3-: 30.9 ± 3.7 meq/l, pH: 7.42 ± 0.07, CO2: 47.9 ± 8.3 mmHg, total Ca2+: 8.08 ± 1.09 mg/dL. Post-filter iCa2+ ranged 0.27-0.36 mmol/l, and patient iCa2+ ranged 0.81-1.24 mmol/l. Mean post-filter RF rate: 3086 ± 164 ml/h, mean ACD-A rate: 298 ± 21 ml/h. Mean blood flow rate: 200 ± 17 ml/min, mean filtration fraction: 39.6 ± 7.2%. Mean effluent flow rate: 38.6 ± 6.7 ml/kg/h (range 28.7-55.8). Mean filter survival was 7 h without anticoagulation, compared to 42.6 h in the ACD-A group (p<0.0001).
Conclusions:
In this pilot study, CVVH using ACD-A for RCA and a Ca2+ -containing RF was safely and effectively used without a continuous Ca2+ infusion. This protocol is a promising solution for maintaining effective CRRT when intravenous calcium is in short supply.
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