eISSN: 2345-2781  
Submitted: 05 Aug 2017

Accepted: 04 Nov 2017
First published online: 13 Dec 2017
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J Renal Inj Prev. 2018;7(3):139-143.
doi: 10.15171/jrip.2018.35

Review

Regional citrate anticoagulation for continuous renal replacement therapy without post-filter monitoring of ionized calcium

Tibor Fülöp 1 * , Sohail Abdul Salim 1, Lajos Zsom 2

1 Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
2 Fresenius Medical Care Hungary Kft, Cegléd, Hungary
*Corresponding author: Tibor Fülöp, M.D., FACP, FASN, Division of Nephrology, University of Mississippi Medical Center, 2500 North State Street, L 504; Jackson, Mississippi 39216-4505. Present address of corresponding author: Department of Medicine - Division of Nephrology, Medical University of South Carolina, Charleston, USA, Email: tiborfulop.nephro@gmail.com

Abstract

Continuous renal replacement therapy (CRRT) modalities are usually preferred in hemodynamically unstable patients in the intensive care units (ICU) but perceived expense and complexity slows broad acceptance. Heparin remains a problematic choice for CRRT anticoagulation due to the risk of bleeding in ICU patients and concerns about heparininduced thrombocytopenia. In this paper, we are describing our simplified regional citrate anticoagulation protocol, utilizing commercially available, premixed solutions exclusively and minimized laboratory monitoring. The protocol is employing Anticoagulant Citrate Dextrose-A (ACD-A) solution for citrate delivery, calcium-free dialysate or replacement fluids and separate calcium infusion, all commercially available in the United States. ACD-A is being infused pre-filter with an hourly rate of 1.5:1 to blood flow rate per minute without specific monitoring of post-filter ionized calcium concentration. Separate infusions of calcium-chloride, sodium phosphate and magnesium chloride are employed via triple lumen catheter to normalize peripheral ionized calcium, phosphate and magnesium concentrations, respectively. The protocol can be conveniently applied in both continuous veno-venous hemofiltration and hemodiafiltration regimens with several of the commercially available CRRT platforms. Built-in features of the protocol are the tendency alkalization and mild hypernatremia, which may be advantageous under select circumstances.

Implication for health policy/practice/research/medical education:

 Establishing continuous renal replacement therapy (CRRT) in the intensive care units in a cost-effective manner remains a challenge. Regional citrate anticoagulation (RCA) during CRRT circumvents the risk of systemic anticoagulation, but represents yet another layer of complexity on an already intricate technology. Abandoning post-filter monitoring of ionized calcium during RCA offers improvement over existing approaches, including reduced complexity, potential for cost-saving and decreased potential for medical errors.

Please cite this paper as: Fülöp T, Abdul Salim S, Zsom L. Regional citrate anticoagulation for continuous renal replacement therapy without post-filter monitoring of ionized calcium. J Renal Inj Prev. 2018;7(3):139-143. doi: 10.15171/jrip.2018.35.

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