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Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy ‐ A Safe and Effective Low‐Dose Protocol
Author(s) -
Poh Cheng Boon,
Tan Poh Choo,
Kam Jia Wen,
Siau Chuin,
Lim Noelle L,
Yeon Wenxiang,
Cui Hai Hua,
Ding Hai Ting,
Song Xiao Ying,
Yan Peng,
Chea Kai Li,
Liu Jin Shu,
Chionh Chang Yin
Publication year - 2020
Publication title -
nephrology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.752
H-Index - 61
eISSN - 1440-1797
pISSN - 1320-5358
DOI - 10.1111/nep.13656
Subject(s) - medicine , renal replacement therapy , urology , anesthesia , protocol (science) , surgery , pathology , alternative medicine
ABSTRACT Aims Regional citrate anticoagulation (RCA) is the preferred mode of anticoagulation for continuous renal replacement therapy (CRRT). Conventional RCA‐CRRT citrate dose ranges from 3 to 5 mmol/L of blood. This study explored the effectiveness of an RCA protocol with lower citrate dose and its impact on citrate‐related complications. Methods This prospective observational study compared two RCA‐CRRT protocols in the intensive care unit. RCA Protocol 1 used an initial citrate dose of 3.0 mmol/L while Protocol 2 started with 2.5 mmol/L. The citrate dose was titrated by sliding scale to target circuit‐iCa 0.26–0.40 mmol/L. Calcium was re‐infused post‐dialyzer and titrated by protocol to target systemic‐iCa 1.01–1.20 mmol/L. Results Two hundred RCA‐CRRT sessions were performed (81 Protocol 1; 119 Protocol 2). The median age was 65.4 years and median APACHE‐II score was 23. Citrate dose for Protocol 1 was significantly higher than Protocol 2 in the first 12 h. The circuit clotting rate was similar in both arms (Protocol 1: 9.9%; Protocol 2: 9.2%; P = 0.881). With Protocol 2, circuit‐iCa levels were 2.42 times more likely to be on target ( P = 0.003) while the odds of hypocalcaemia was 4.67 times higher with Protocol 1 ( P < 0.001). There was a wider anion gap was noted with Protocol 1, which suggests a propensity for citrate accumulation with higher citrate exposure. Conclusion The RCA protocol with a lower initial citrate dose of 2.5 mmol/L blood had less citrate‐related complications with no loss of efficacy. A more precise RCA prescription at the start of treatment avoids unnecessary citrate exposure and improves safety.