Tibor Fülöp
1*, Sohail Abdul Salim
1, Lajos Zsom
21 Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
2 Fresenius Medical Care Hungary Kft, Cegléd, Hungary
*Corresponding Author: *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.