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Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation in Children with Liver Dysfunction/Failure
Edin Botan1, Ayşen Durak2, Emrah Gün1
1Division of Pediatric Intensive Care, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey.
Insights
Regional citrate anticoagulation (RCA) during continuous renal replacement therapy (CRRT) in pediatric liver failure patients showed no significant adverse effects. Close monitoring of calcium, lactate, and prothrombin time is recommended to manage citrate accumulation risks.
Area of Science:
- Pediatric Intensive Care Medicine
- Nephrology
- Hepatology
Background:
- Regional citrate anticoagulation (RCA) is an alternative for continuous renal replacement therapy (CRRT), but citrate accumulation poses a risk.
- Liver failure (LF) in pediatric patients presents complex management challenges, often requiring CRRT.
- Assessing the safety and efficacy of RCA in this vulnerable population is crucial.
Purpose of the Study:
- To evaluate the safety and potential complications of RCA during CRRT in pediatric patients with liver failure.
- To investigate the impact of RCA on acid-base status, liver function tests, and indicators of citrate toxicity.
- To identify key parameters for monitoring citrate accumulation in this patient group.
Main Methods:
- A retrospective study of 47 pediatric patients with liver failure admitted to the PICU between May 2019 and April 2021.
- Analysis of 10 patients who received RCA during CRRT, examining demographic data, indications for CRRT, and clinical outcomes.
- Comparison of laboratory values (total/ionized calcium, lactate, pH, bicarbonate, liver enzymes, bilirubin) before and after RCA-CRRT.
Main Results:
- No significant differences were observed in liver transaminases, liver function tests, acid-base status, or citrate toxicity markers (calcium levels, lactate, pH, bicarbonate) before and after RCA-CRRT.
- The most common indication for CRRT was hepatorenal syndrome (40%).
- No RCA-related complications or dialysis interruptions due to citrate accumulation (e.g., Total Ca/ionized Ca >2.5) occurred.
Conclusions:
- RCA-CRRT appears to be a safe option for pediatric patients with liver failure, with no observed adverse effects on acid-base balance or liver function.
- Close daily monitoring of total/ionized calcium ratio, serum lactate, and prothrombin time is essential for managing potential citrate accumulation.
- Further research may be warranted to confirm these findings in larger cohorts.
Abstract:
Regional citrate anticoagulation (RCA) is an option but citrate accumulation is risk and it is a giving up cause for this situation. This retrospective study was conducted in the pediatric intensive care unit (PICU) between May 2019 and April 2021. We investigated 47 patients with liver failure (LF) in our PICU, and RCA during continuous renal replacement therapy (CRRT) was applied to 10 (21.3%) of them. Half of them were male (n: 5/10), their mean age was 104.7 ± 66.20 months. Nine of them needed vasoactive support during follow-up. The most common indication for CRRT was hepatorenal syndrome (40%). There was no significant difference between liver transaminases and liver function tests before and after CRRT (p > 0.05). In terms of citrate toxicity of the patients, there was no significant difference between total calcium/ionized calcium, lactate level, pH and bicarbonate values before and after CRRT (p > 0.05). The mean total CRRT time was 110.2 ± 118.2 h, and the mean circuit lifespan was 43.8 ± 48.7 h; the mean number of circuits was 2.7 ± 2.4. Total Ca/ionized Ca >2.5 was a clinically relevant endpoint, but no patient interrupted dialysis for this cause. There was no complication about RCA. This study did not observe any adverse effects on acid-base status, transaminases, an increase in bilirubin during RCA-CRRT treatment in pediatric patients with LF. Total calcium/ionized calcium ratio, serum lactate level and prothrombin time level should be closely monitored daily in terms of citrate accumulation in this patient group.
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