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- Title
Citrate as the Sole Buffer and Anticoagulant in Continuous Veno-Venous Hemofiltration (CVVH).
- Authors
Schmitz, M.; Taskaya, G.; Plum, J.; Steiner, S.; Grabensee, B.; Hetzel, G. R.
- Abstract
Objective: Though different methods of regional anticoagulation in continuous renal replacement therapy (CRRT) were described in the past, there is still no accredited procedure in critically ill patients with ARF and bleeding complications. A few groups described systems of regional citrate anticoagulation in CVVH. We treated 16 patients using a system, in which citrate is used both as an anticoagulant as well as the sole buffer substance in CVVH. Methods: Our substitution fluid (citrate 12 mmol/l, Na 140m mol/l, Mg 0.75 mmol/l, K 2 mmol/l, Cl 104.7 mmol/l, Glucose 1 g/l, provided by Fresenius Medical Care, Germany) was used in the predilution mode with a constant relation between blood flow (120 ml/min) and substitution flow (2,500 ml/hour). It was possible to adjust both parameters in parallel according to the needed dialysis dose. The necessary Ca-substitution was administered using Ca-gluconate i.v. (7 ± 1mval/h, ionised Ca 0.9 ± 1.2 mmol/l). Anticoagulation was thereby limited to the extracorporeal circuit and Ca-haemostasis was maintained. 16 patients (56.7 ± 15.3 years, 5 female) with acute renal failure on mechanical ventilation at risk of bleeding were treated as described above, 4 of them for 8 hours, 4 for 24 hours and 8 as long they needed CRRT (7.7 ± 5.7 days). Results: We could achieve a stable acid base balance in all patients (table 1) except for one patient, whose refractory acidosis persisted even after returning to conventional bicarbonate CVVH. This patient died 2 days later due to severe sepsis. None of the patients developed hypocalcaemia. As the anticoagulation was limited to the extracorporeal circuit (ACT of patient 115 ± 33 sec, ACT post filter 515 ± 256 sec), we observed no bleeding complications at all. Conclusions: Citrate is capable of providing both the anticoagulation within the extracorporeal circuit as well as the control of the acid-base balance in critically ill patients in acute renal failure. An additional bicarbonate substitution normally is not necessary. Our system is easy to apply, save and variable with respect to dialysis dose as long as a constant ratio between blood and substitution flow is maintained. However, close Monitoring of the patients calcium homoeostasis is necessary. An ongoing randomised prospective study is currently evaluating the system with respect to safety and efficacy in a larger number of patients.
- Subjects
HOMEOSTASIS; DIALYSIS (Chemistry); ACUTE kidney failure; KIDNEY diseases; HEMORRHAGE
- Publication
Kidney & Blood Pressure Research, 2004, Vol 27, Issue 5/6, p304
- ISSN
1420-4096
- Publication type
Article