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Cyclophosphamide and regional citrate anticoagulation: A sour combination?
Tim Hendra1, Jonathan Simon2, Alastair Lowe3
1University Hospital Southampton, Southampton, UK.
Journal of the Intensive Care Society
|November 11, 2017
Summary
A patient on cyclophosphamide developed severe acute kidney injury and experienced persistent low ionized calcium during citrate anticoagulation for renal replacement therapy. This suggests cyclophosphamide may impair citrate metabolism, leading to calcium chelation.
Area of Science:
- Nephrology
- Pharmacology
- Critical Care Medicine
Background:
- Cyclophosphamide is an alkylating agent used in treating multiple myeloma.
- Acute kidney injury (AKI) is a potential complication in patients with multiple myeloma.
- Regional citrate anticoagulation (RCA) is commonly used for renal replacement therapy (RRT) in AKI.
Purpose of the Study:
- To report a case of severe hypocalcemia during RCA in a patient with AKI receiving cyclophosphamide.
- To explore the potential interaction between cyclophosphamide and citrate metabolism.
- To highlight the importance of monitoring calcium levels during RCA in patients on specific chemotherapies.
Main Methods:
- Case report of a female patient in her 70s with multiple myeloma and grade III AKI.
- Initiation of RRT with RCA.
- Monitoring of systemic ionized calcium levels and adjustment of calcium infusion.
- Change of anticoagulation from RCA to heparin due to persistent hypocalcemia.
- Review of cyclophosphamide's known metabolic pathways and potential interactions.
Main Results:
- The patient developed persistent, severe hypocalcemia (low ionized calcium) during RCA.
- Increasing post-filter calcium return temporarily improved ionized calcium levels.
- The total-to-ionized calcium ratio increased, indicating citrate accumulation or impaired metabolism.
- Anticoagulation was switched to heparin to avoid further citrate accumulation.
- The patient's condition improved after the anticoagulation change.
Conclusions:
- Cyclophosphamide may interfere with citrate metabolism, leading to persistent hypocalcemia during RCA.
- This interaction could be due to cyclophosphamide's effect on enzymes in the tricarboxylic acid cycle.
- Close monitoring of ionized calcium and consideration of alternative anticoagulation strategies are crucial for patients on cyclophosphamide undergoing RCA.
Keywords:
Regional citrate anticoagulationcyclophosphamideinteractionrenal replacement therapytricarboxylic acid cycleMore Related Videos
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