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CRRT Regional Anticoagulation Using Citrate in the Liver Failure and Liver Transplant Population
Rob Wonnacott1, Brandi Josephs, Jill Jamieson
1Surgical Intensive Care Unit (Mr Wonnacott), Cardiovascular Intensive Care Unit, Samuel and Jean Frankel Cardiovascular Center (Ms Josephs), and Acute/Nocturnal Hemodialysis Interventional Nephrology Unit (Ms Jamieson), University of Michigan Health Systems, Ann Arbor.
Abstract:
Regional citrate for continuous renal replacement therapy (CRRT) use in patients with liver failure or post-liver transplant has been considered a contraindication because of the risk of citrate toxicity development. Regional citrate has the benefit of decreased bleeding risks over systemic anticoagulation; therefore, it is of great benefit to the coagulopathic and surgical populations. This article analyzes current empiric data and compares with a case study specifically related to liver failure, liver transplant, and CRRT use. We found that the use of a total serum to ionized calcium ratio was much more reliable in measuring liver function than liver enzyme figures. This when paired with a citrate-reduction guideline based on serum to ionized calcium ratios provided effective, early management of citrate toxicity. Using new measurements to calculate liver metabolism of citrate and using a new citrate-reducing guideline allow the bedside practitioner to use regional citrate anticoagulation in patients with liver failure and liver transplant who require CRRT.
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