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A simplified protocol of regional citrate anticoagulation with phosphate-containing solutions in infants and children treated with continuous kidney replacement therapy

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Abstract

Background

Regional citrate anticoagulation (RCA) is the preferred modality of anticoagulation used in continuous kidney replacement therapy (CKRT) in adults and less extensively in children. Potential metabolic complications limit widespread use in infants, neonates, and in children with liver failure.

Methods

We report our experience with a simplified protocol in 50 critically ill children, infants, and neonates, some of them with liver failure, with commercially available solutions containing phosphorous and higher concentration of potassium and magnesium.

Results

RCA allowed attainment of a mean filter lifetime of 54.5 ± 18.2 h, 42.5% of circuits lasted more than 70 h, and scheduled change was the most frequent cause of CKRT interruption. Patient Ca++ and circuit Ca++ were maintained in the target range with mean values of 1.15 ± 0.13 mmol/l and 0.38 ± 0.07 mmol/l, respectively. No session had to be stopped because of metabolic complications. The most frequent complications were hyponatremia, hypomagnesemia, and metabolic acidosis mostly related to primary disease and critical illness. No session had to be stopped because of citrate accumulation (CA). Transitory CA occurred in 6 patients and was managed without requiring RCA interruption. No patients with liver failure presented CA episodes.

Conclusions

In our experience, RCA with commercially available solutions was easily applied and managed in critically ill children, even in patients with low weight or with liver failure. Solutions containing phosphate and higher concentrations of magnesium and potassium allowed reduction of metabolic derangement during CKRT. Prolonged filter life was ensured with no detrimental effects on patients and reduced staff workload.

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Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on request.

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Authors and Affiliations

  1. Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165, Rome, Italy

    Andrea Cappoli, Raffaella Labbadia, Luca Antonucci & Isabella Guzzo

  2. Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165, Rome, Italy

    Gabriella Bottari

  3. Department of Emergency, Anaesthesia and Intensive Care, Pediatric Intensive Care Unit, Bambino Gesù Children’s Hospital and Research Institute, Piazza Sant’Onofrio 4, 00165, Rome, Italy

    Emanuele Rossetti

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  1. Andrea Cappoli
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Cappoli, A., Labbadia, R., Antonucci, L. et al. A simplified protocol of regional citrate anticoagulation with phosphate-containing solutions in infants and children treated with continuous kidney replacement therapy. Pediatr Nephrol 38, 3835–3844 (2023). https://doi.org/10.1007/s00467-023-05994-y

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