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Regional citrate anticoagulation with a substitute containing calcium for continuous hemofiltration in children
Ke Bai1, Chengjun Liu, Fang Zhou
1Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Children Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, P.R. China.
Insights
Regional citrate anticoagulation (RCA) with calcium in the replacement fluid is safe and effective for pediatric continuous hemofiltration (CHF). This simplified RCA protocol in children achieved target in vitro and in vivo calcium levels with minimal complications.
Area of Science:
- Nephrology
- Pediatric Critical Care
- Biochemistry
Background:
- Regional citrate anticoagulation (RCA) is recommended for adults in continuous hemofiltration (CHF) due to effective anticoagulation with minimal systemic effects.
- Traditional RCA protocols use calcium-free replacement fluids, necessitating careful calcium monitoring.
- This study explores a simplified RCA protocol using a calcium-containing replacement fluid in pediatric patients undergoing CHF.
Purpose of the Study:
- To evaluate the safety and efficacy of a simplified regional citrate anticoagulation (RCA) protocol for continuous hemofiltration (CHF) in children.
- To assess the impact of using a calcium-containing replacement fluid on in vitro and in vivo ionic calcium levels.
- To determine the incidence of circuit clotting, bleeding, and acid-base disturbances with this modified RCA protocol.
Main Methods:
- An observational, retrospective study analyzed 59 pediatric patients undergoing 106 CHF sessions.
- Ionic calcium (iCa), sodium, bicarbonate, and pH levels were monitored pre- and post-treatment.
- In vitro and in vivo iCa levels, circuit parameters (transmembrane pressure), filter clotting, and bleeding events were recorded.
Main Results:
- The simplified RCA protocol successfully achieved target in vitro (88.5%) and in vivo (95.4%) ionic calcium levels.
- Most treatments were within target ranges, with only minor deviations in calcium levels post-treatment.
- No sodium disorders were observed, and there was a trend towards alkalemia rather than acidemia after treatment.
Conclusions:
- Regional citrate anticoagulation (RCA) using a simplified protocol with a calcium-containing replacement fluid is safe and effective for pediatric continuous hemofiltration (CHF).
- Close monitoring of in vitro calcium levels and appropriate citrate adjustments are crucial for successful implementation.
- This approach offers a viable alternative for anticoagulation in pediatric CRRT, potentially simplifying management.
Abstract:
Regional citrate anticoagulation (RCA) was recommended as the first treatment option for adults by the Kidney Disease Improving Global Outcomes Kidney Foundation in 2012, for the characteristic of sufficient anticoagulation in vitro, but almost no anticoagulation in vivo. Traditionally, the substitute for RCA is calcium-free. This study investigated a simplified protocol of RCA for continuous hemofiltration (CHF) in children using a commercially available substitute containing calcium.An analytical, observational, retrospective study assessed 59 pediatric patients with 106 sessions and 3580 hours of CHF. Values before and after treatment were compared, including Na, ionic calcium (iCa) and HCO3 concentrations, pH, and the ratio of total calcium to iCa (T/iCa). In addition, in vivo and in vitro iCa, treatment time, sessions with continuous transmembrane pressure >200 mm Hg, and sessions with clotting and bleeding were recorded.The average treatment time was 33.8 ± 10.1 hours. In vitro, 88.5% of iCa achieved the target (0.25-0.35 mmol/L), and in vivo, 95.4% of iCa achieved the target (1.0-1.35 mmol/L). There were 8 sessions with a transmembrane pressure >200 mm Hg and 3 sessions with filters clotted. After treatment, there were 2, 1, and 2 sessions with T/iCa > 2.5 (implying citrate accumulation), iCa < 0.9 mmol/L, and iCa > 1.35 mmol/L. No sodium disorders were recorded. There were fewer cases of acidemia and more cases of alkalemia after treatment compared to before.RCA-CHF with a substitute containing calcium and close monitoring could be a safe and effective treatment for children. In addition, the calcium test site in vitro and the adjustment of citrate should be given strict attention.
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