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Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy

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Abstract

Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.

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Data availability

The data that support the findings of this study are available from the corresponding author, C. Warnar, upon reasonable request.

Abbreviations

AKI:

Acute kidney injury

APACHE III:

Acute Physiology Age and Chronic Health Evaluation-III

CVVH:

Continuous venovenous hemofiltration

CVVHD:

Continuous venovenous hemofiltration with dialysis

CRRT:

Continuous renal replacement therapy

ICU:

Intensive care unit

PDMS:

Patient data management system

RIFLE:

Risk—injury—failure—loss—end stage kidney disease

RRT:

Renal replacement therapy

SAPS III:

Simplified Acute physiology Score-III

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Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by EF, PAK, PES, CW and TS. The first draft of the manuscript was written by CW and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to C. Warnar.

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Conflict of interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Ethical approval and consent for participation

The project was evaluated by the local ethical review board (2018_57) who waived the requirement to obtain informed consent in view of the observational design of the study.

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Appendix: Local protocol of adjustments to systemic ionized calcium and post-filter ionized calcium

Appendix: Local protocol of adjustments to systemic ionized calcium and post-filter ionized calcium

Systemic ionized calcium (mmol/L)

Adjustment calcium dosage (calcium/dialysate*)

Post-filter ionized calcium (mmol/L)

Adjustment citrate dosage (citrate/blood*)

 > 1.45

Decrease with 0.6 mmol/L (inform the physician)

 > 0.45

Increase with 0.3 mmol/L (inform the physician)

1.31–1.45

Decrease with 0.4 mmol/L

0.41–0.45

Increase with 0.2 mmol/L

1.21–1.30

Decrease with 0.2 mmol/L

0.35–0.40

Increase with 0.1 mmol/L

1.12–1.20

No adjustments

0.25–0.34

No adjustments

1.05–1.11

Increase with 0.2 mmol/L

0.20–0.24

Decrease with 0.1 mmol/L

0.95–1.04

Increase with 0.4 mmol/L

 < 0.20

Decrease with 0.2 mmol/L

 < 0.95

Increase with 0.6 mmol/L (inform the physician)

  

*Dosage of calcium and citrate are dependent of the used dialysate and blood flow.

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Warnar, C., Faber, E., Katinakis, P.A. et al. Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy. J Clin Monit Comput 36, 871–877 (2022). https://doi.org/10.1007/s10877-021-00719-8

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  • DOI: https://doi.org/10.1007/s10877-021-00719-8

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