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Plasma exchange therapy is applied for treatment of severe immune diseases of multiple organ systems and severe liver diseases by removing pathogenic factors and regulating immune function. Regional citrate anticoagulation has no effect on systemic coagulation function and does not increase bleeding risk, and it is one of the optional anticoagulation methods for plasma exchange therapy. This article reviews recent literature on simple plasma exchange therapy with regional citrate anticoagulation to provide a reference for clinical application of this therapy.
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Objective:To analyze the possible causes of arrhythmia in patients receiving continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA).Methods:A retrospective cohort study was conducted. All patients underwent RCA-CRRT treatment from January 1, 2020 to October 31, 2020 in the intensive care unit (ICU) of Tianjin Third Central Hospital were enrolled. The patients were divided into arrhythmia group and non-arrhythmia group according to whether arrhythmia occurred. The gender, age, acute physiology and chronic health evaluationⅡ(APACHEⅡ) score, catheterization site, underlying diseases, electrocardiogram (ECG), electrolytes [total calcium, serum free calcium (iCa 2+), phosphorus, magnesium, potassium] and blood gas analysis (pH value, HCO 3-) of patients in the two groups were recorded. The changes of ECG were observed, the differences in electrolyte and blood gas analysis indexes between the two groups of patients at different time points (before CRRT, 24, 48, 72 hours after CRRT, and when arrhythmia occurred) were compared. Results:A total of 86 RCA-CRRT patients were enrolled, of which 12 cases (13.95%) had arrhythmia, and the remaining 74 cases (86.05%) had no arrhythmia. The average time for the occurrence of arrhythmia in the 12 patients was (44.00±16.82) hours. There was no significant ST-segment change in the ECG when the arrhythmia occurred compared with that before CRRT, the total calcium level was significantly higher than that before CRRT (mmol/L: 2.48±0.40 vs. 2.13±0.35, P < 0.05), the blood magnesium level was significantly lower than that before CRRT (mmol/L: 0.73±0.20 vs. 0.95±0.25, P < 0.05). There was no significant difference in iCa 2+, blood phosphorus, blood potassium, pH value and HCO 3- between before CRRT and when arrhythmia occurred. Over time, the total calcium levels in the two groups increased, and there was a statistical difference between the 48 hours after CRRT and before CRRT (mmol/L: 2.48±0.33 vs. 2.13±0.35 in the arrhythmia group, and 2.30±0.22 vs. 2.15±0.48 in non-arrhythmia group, both P < 0.05). The linear change trend of iCa 2+, pH value and HCO 3- was not obvious in the two groups. The blood phosphorus and blood magnesium levels in the two groups decreased. The blood potassium in the arrhythmia group decreased, however, the blood potassium level in non-arrhythmia group did not change significantly. The total calcium level in the arrhythmia group was significantly higher than that in the non-arrhythmia group at 72 hours after CRRT (mmol/L: 2.69±0.35 vs. 2.45±0.23, P < 0.05); however, there was no significant difference in serum iCa 2+, phosphorus, magnesium, potassium, pH value and HCO 3- between the two groups. Conclusion:Patients receiving RCA-CRRT were less likely to develop arrhythmia, the causes may be related to the accumulation of citric acid and electrolyte disturbances such as calcium, phosphorus, and magnesium.
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@#Objective To research the influence of anticoagulation to blood clotting function in patients who experienced cardiopulmonary bypass surgery under continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA), low molecular weight heparin (LMWH) anticoagulation and non-anticoagulation. Methods We retrospectively analyzed the clinical data of 146 patients who underwent CRRT after cardiopulmonary bypass surgery between January 2014 and December 2016. There were 98 males and 48 females at age of 60.51±14.29 years. All CRRT patients were allocated into three groups including a RCA group, a LMWH group, and a non-anticoagulation group, which were compared in terms of convention coagulation tests, platelet counts, thromboelastography, circuit lifespan and transfusion. Results Three hundred and fifty four CRRT patients were selected from patients above, including 152 patients in the LMWH group, 160 in the RCA group, and 42 in the non-anticoagulation group. The difference of CRRT circuits time among three groups was statistically different (P=0.023). And multiple comparison showed that the circuit lifespan of the RCA group was significantly longer than that of the non-anticoagulation group (34.50 h ranged 14.00 h to 86.00 h vs.15.00 h ranged 12.00 h to 50.88 h, P=0.033). One hundred and fifty-five CRRT patients last beyond 24 hours with same anticoagulation were selected, the results of coagulation tests, and the difference between CRRT starting and after 24 hours were compared. The difference of Angle and maximum amplitude(MA) of pre- and post-CRRT were significantly different among three groups by one-way ANOVA (P=0.004, 0.000), as well as between the RCA group and the LMWH group by multiple comparison (P=0.004, 0.000). There was no statistical difference in frequencies and doses of the transfusion of fresh frozen plasma and platelet among three groups. Conclusion RCA is an effective anticoagulation which may prolong circuit lifespan and has small impact on the coagulation function of patients who undergo CRRT after cardiopulmonary bypass surgery.
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Objective To investigate the application of citrate injected by dialysis pump in regional citrate anticoagulation (RCA) for child continuous hemofiltration(CHF). Methods The clinical data of 49 children patients with RCA-CHF with citrate anticoagulation in ICU of the Affiliated Children's Hospital of Chongqing Medical University from September 2015 to January 2017 were retrospectively analyzed. All cases were divided into the traditional group(20 cases) for conducting RCA-CHF treatment and improved group(29 cases,dialysis pump injection of citric acid) for conducting RCA-CHF under CHF mode. The occurence situation of common complications such as infusion pump bubble alarming, blood undesirable collection, bleeding and coagulation, and complications such as filter lifetime and citrate anticoagulation were observed. Results The bubble alarming and filter lifetime had statistical difference between the two groups(P<0.05). The biochemical indicators before and after treatment, and Na+ , iCa2+ , TCa2+/iCa2+ and HCO3- before and after treatment had statistical difference between the two groups. But Na+ , iCa2+ , TCa2+ /iCa2+and HCO3- before and after treatment had no statistical difference between the improved group and traditional group(P>0.05). Conclusion The improved technology of dialysis pumps instead of citrate pumps can more safely and more effectively use in child RCA-CHF treatment.
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Objective To explore the advantages and disadvantages of regional citrate anticoagulation (RCA) mode by comparing to non-anticoagulation mode for continuous renal replacement therapy (CRRT)in patients with acute kidney injury (AKI) at high risk of bleeding.Methods The criterion for inclusion of patients was stage 3 of AKI selected according to Kidney Disease Improving Global Outcomes guideline.And those patients had high risk factors of bleeding as well as such as post-major opertion,coagulopathy (prothrombin time or activated partial thromboplastin time ＞ 1.5 times the normal control,or prothrombin time ＞ 18 s,activated partial thromboplastin time ＞ 60 s),thrombocytopenia (＜ 50 × 109/L),and combined therapy with anticoagulant,antiplatelet or thrombolytic drugs.The CRRT was initiated within 4 h after randomization.The exclusion criteria was severe liver failure (serum total bilirubin ＞ 171 μmmol/L).Continuous venovenous hemodiafiltration mode was employed in both groups,and the filter was changed routinely every 72 h,unless clotting developed in the extracorporeal circuit.Because the commercial calcium-free dialysate was not available in the market,this dialysate was prepared by the intensive care unit (ICU) nurses.Results Thirty two patients were equally divided in those two groups,and most of them were admitted to ICU after major surgery.There were no significant differences between the groups in data of blood gas analysis,hepatic/renal/coagulative functions,electrolyte,hemoglobin and platelet count before or after CRRT.The filter was more durable in RCA mode than that in non-RCA mode determined through Kaplan-Meier curve analysis (x2 =9.707,P =0.002),with the mean time (h) 36.01 (26.61-45.42)vs.22.04 (18.35-25.73).More packed red blood cells and platelet were required in non-RCA mode than those in RCA mode during CRRT.There was no significant difference in ICU mortality between RCA mode and non-RCA mode with 7/16 vs.9/16,P =0.724.Severe blood loss and malignant arrhythmia events did not occur in both modes.The body temperature,systemic electrolyte,post-filter ionized calcium levels and the ratio of total to ionized systemic calcium were basically preserved at a target range in RCA group during CRRT.Conclusions RCA-CRRT is a safe and effective mode for AKI patient with high risk of bleeding,which can extend the durability of filter,and lower the risk of blood loss.However,the study failed to show a mortality benefit with the RCA mode,and it could also increase the workload of nurses under the current domestic setting.
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Objective To explore the advantages and disadvantages of regional citrate anticoagulation (RCA) mode by comparing to non-anticoagulation mode for continuous renal replacement therapy (CRRT)in patients with acute kidney injury (AKI) at high risk of bleeding.Methods The criterion for inclusion of patients was stage 3 of AKI selected according to Kidney Disease Improving Global Outcomes guideline.And those patients had high risk factors of bleeding as well as such as post-major opertion,coagulopathy (prothrombin time or activated partial thromboplastin time ＞ 1.5 times the normal control,or prothrombin time ＞ 18 s,activated partial thromboplastin time ＞ 60 s),thrombocytopenia (＜ 50 × 109/L),and combined therapy with anticoagulant,antiplatelet or thrombolytic drugs.The CRRT was initiated within 4 h after randomization.The exclusion criteria was severe liver failure (serum total bilirubin ＞ 171 μmmol/L).Continuous venovenous hemodiafiltration mode was employed in both groups,and the filter was changed routinely every 72 h,unless clotting developed in the extracorporeal circuit.Because the commercial calcium-free dialysate was not available in the market,this dialysate was prepared by the intensive care unit (ICU) nurses.Results Thirty two patients were equally divided in those two groups,and most of them were admitted to ICU after major surgery.There were no significant differences between the groups in data of blood gas analysis,hepatic/renal/coagulative functions,electrolyte,hemoglobin and platelet count before or after CRRT.The filter was more durable in RCA mode than that in non-RCA mode determined through Kaplan-Meier curve analysis (x2 =9.707,P =0.002),with the mean time (h) 36.01 (26.61-45.42)vs.22.04 (18.35-25.73).More packed red blood cells and platelet were required in non-RCA mode than those in RCA mode during CRRT.There was no significant difference in ICU mortality between RCA mode and non-RCA mode with 7/16 vs.9/16,P =0.724.Severe blood loss and malignant arrhythmia events did not occur in both modes.The body temperature,systemic electrolyte,post-filter ionized calcium levels and the ratio of total to ionized systemic calcium were basically preserved at a target range in RCA group during CRRT.Conclusions RCA-CRRT is a safe and effective mode for AKI patient with high risk of bleeding,which can extend the durability of filter,and lower the risk of blood loss.However,the study failed to show a mortality benefit with the RCA mode,and it could also increase the workload of nurses under the current domestic setting.
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Objective To investigate the efficacy and safety of regional citrate anticoagulation (RCA) for continuous veno-venous hemofiltration (CVVH) in patients with severe trauma.Methods Sixty-four patients with severe trauma who needed to apply continuous renal replacement therapy (CRRT) and were admitted into the department of critical care medicine in Tianjin Hospital from June 2013 to August 2015 were enrolled in the study.According to the patient's actual condition,they were divided into two groups:no anticoagulant group (29 cases) and RCA group (35 cases).The filter lifetime,after treatment the activated partial thromboplastin time (APTT),acid-base balance,free calcium ([Ca2+]i) and serum sodium (Na+) concentrations,bleeding episodes were compared between the two groups.Results The average filter lifetime in RCA group was longer than that in no anticoagulant group (hours:50.7 ± 11.3 vs.4.9 ± 1.2,P ＜ 0.01).After the end of treatment,the levels of APTT (s:30.7 ± 8.8 vs.32.1 ± 7.3),pH value (7.41 ± 0.09 vs.7.40 ± 0.07),[Ca2+]i (mmol/L:2.13 ± 0.20 vs.2.21 ± 0.17),and Na+ (mmol/L:139 ± 8 vs.141 ± 6) were ofno significant differences between the RCA group and the no anticoagulant group (all P ＞ 0.05).The incidence of clinicalbleeding in RCA group was lower than that in no anticoagulant group [2.9％ (1/35) vs.13.8％ (4/29)],but the differencewas not statistically significant (P ＞ 0.05).Conclusions RCA-CVVH is a safe and effective therapeutic method inpatients with severe trauma who need for CRRT,the stability of internal environment is not affected and no incidence ofclinical bleeding event is increased.
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ObjectiveTo establish a mathematical formula for choosing the manner of replacement fluid infusion in continuous renal replacement therapy (CRRT), so as to provide the basis for improving the treatment effect. Methods A mathematical formula for choosing the manner of replacement fluid infusion with continuous veno-venous hemofiltration (CVVH) was taken as an example, and it was compared with the result of standard replacement fluid in order to analyze the effect of different manners of infusion.① Comparison parameters: the plasma volume (Vreturn) and some electrolyte concentration (Creturn) in back way of CRRT (if other thing was solute, filter coefficient should be 1.0).② Research objects: the actual replacement fluid (for example, the most complex should be sorted into A and B type) mode (pre or post) was compared with the standard replacement fluid (the A and B in one).③ Based on the formula of standard replacement, four equations in different conditions were derived: pre-dilution and post-dilution mode; same direction and same ratio; same direction and different ratio; different direction and same ratio; different direction and different ratio.Results The calculated results of Vreturn (except hematocrit) and Creturn were same to the standard only following the rule of same direction and ratio for A and B no matter pre-dilution mode or post-dilution mode, and it was different from the standard in others. In pre-dilution mode and post-dilution mode, it showed:① A and B in same direction and different ratio: Vreturn and Creturn were different from the standard for the alterative ratio of B.② A and B in different direction and same ratio: Vreturn was same to the standard, but Creturn was different from the standard for the completely different and more complex computational formula.③ A and B in different direction and different ratio: both Vreturn and Creturn were different from the standard. The different Vreturn was due to the different ratio of B. The different Creturn was caused by different ratio of B and the completely different computational formula.Conclusions① For parts of replacement fluid which must be separated ( for example, bicarbonate formula ), the result is same to the standard, and is predicted and mastered only following the rule of same direction and ratio. Otherwise, we need to calculate the two parameters over and over again. The result will run out of our judgment. The wrongness of losing water and electrolyte disorders maybe come out.② Accordingly,the formula could be used to analyze the same case like the separated replacement infusion, for example, a large number of citrates as regional anticoagulation were infused only in the front of filter, while the replacement fluid can be done in varied forms.
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Regional citrate anti-coagulation for continuous renal replacement therapy chelates calcium to produce the anti- coagulation effect. We hypothesise that a calcium-free replacement solution will require less citrate and produce fewer metabolic side effects. Fifty patients, in a Medical Intensive Care Unit of a tertiary teaching hospital (25 in each group), received continuous venovenous hemofiltration using either calcium-containing or calcium-free replacement solutions. Both groups had no significant differences in filter life, metabolic alkalosis, hypernatremia, hypocalcemia, and hypercalcemia. However, patients using calcium-containing solution developed metabolic alkalosis earlier, compared to patients using calcium-free solution (mean 24.6 hours,CI 0.8-48.4 vs. 37.2 hours, CI 9.4-65, P = 0.020). When calcium-containing replacement solution was used, more citrate was required (mean 280ml/h, CI 227.2-332.8 vs. 265ml/h, CI 203.4-326.6, P = 0.069), but less calcium was infused (mean 21.2 ml/h, CI 1.2-21.2 vs 51.6ml/h, CI 26.8-76.4, P ≤ 0.0001).
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Aged , Alkalosis/chemically induced , Alkalosis/epidemiology , Anticoagulants/therapeutic use , Calcium/adverse effects , Female , Hemodialysis Solutions/therapeutic use , Hemofiltration/instrumentation , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Renal Replacement Therapy , Retrospective StudiesABSTRACT
Continuous renal replacement therapy (CRRT) has been used increasingly for the management of renal failure in hemodynamically unstable and critically ill patients. CRRT requires anticoagulation, usually with heparin, to prevent clotting in the extracorporeal circuit. Systemic heparinization is associated with a high rate of bleeding when used during CRRT in critically ill patients. We applied regional citrate anticoagulation for CRRT to two critically ill patients with high bleeding risk using calcium containing commercial solutions. We conclude that regional citrate anticoagulation with commercial calcium containing solution can be used alternative to heparin for CRRT in patients with high bleeding risk.