Submitted: 05 Aug 2017
Accepted: 04 Nov 2017
ePublished: 13 Dec 2017
EndNote EndNote

(Enw Format - Win & Mac)

BibTeX BibTeX

(Bib Format - Win & Mac)

Bookends Bookends

(Ris Format - Mac only)

EasyBib EasyBib

(Ris Format - Win & Mac)

Medlars Medlars

(Txt Format - Win & Mac)

Mendeley Web Mendeley Web
Mendeley Mendeley

(Ris Format - Win & Mac)

Papers Papers

(Ris Format - Win & Mac)

ProCite ProCite

(Ris Format - Win & Mac)

Reference Manager Reference Manager

(Ris Format - Win only)

Refworks Refworks

(Refworks Format - Win & Mac)

Zotero Zotero

(Ris Format - Firefox Plugin)

J Renal Inj Prev. 2018;7(3): 139-143.
doi: 10.15171/jrip.2018.35

Scopus ID: 85050145206
  Abstract View: 1919
  PDF Download: 1193


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, tiborfulop.nephro@gmail.com


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.
Keywords: Continuous renal replacement therapy, Hemofiltration, Medical errors, Regional citrate anticoagulation, Thrombocytopenia, Intensive care unit

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.

First Name
Last Name
Email Address
Security code

Abstract View: 1919

Your browser does not support the canvas element.

PDF Download: 1193

Your browser does not support the canvas element.