Discrepant post filter ionized calcium concentrations by common blood gas analyzers in CRRT using regional citrate anticoagulation (original) (raw)
Related papers
Clinical Kidney Journal
Background Current guidelines recommend monitoring of post-filter ionized calcium (pfCa) when using regional citrate anticoagulation during continuous renal replacement therapy (RCA-CRRT) to determine citrate efficiency for prevention of filter clotting. However, the reliability of pfCa raises the question of whether routine monitoring is required. Reducing the frequency of pfCa monitoring could potentially reduce costs and workload. Our objective was to test the efficacy and safety of no pfCa monitoring among critically ill patients receiving RCA-CRRT. Methods This study was a non-inferiority randomized controlled trial conducted between January 2021 and October 2021 at King Chulalongkorn Memorial Hospital, Thailand. Critically ill patients who were treated with RCA-CRRT were randomized to receive either standard pfCa monitoring (aiming pfCa level of 0.25-0.35 mmol/L), or no pfCa monitoring, in which a constant rate of citrate infusion was maintained at pre-determined citrate conce...
Annals of Clinical Biochemistry: International Journal of Laboratory Medicine, 2017
Background Measurements of ionized calcium (Ca2+) at concentrations less than 0.3 mmol/L are required for postfilter control in patients who receive extracorporeal circulation with sodium citrate anticoagulation. This study evaluates the stability of the Ca2+ measurements at such concentrations. Methods The stability of the Ca2+ measurements was tested by measuring daily the external standard Qualicheck concentration 3 s7950, Radiometer (0.22–0.25 mmol/L) by blood gas instruments ABL800 and ABL90, Radiometer. Two different Ca2+ membrane lots were tested for the usual membrane lifetime of 12 weeks at ABL800 instruments. For the ABL90 instrument, the sensor cassette (with Ca2+ membrane and electrode) was replaced after four weeks as required. Results We observed over 40% Ca2+ increase within the usual 12 weeks lifetime of the Ca2+ membrane at the ABL800 instruments. Measurements of Ca2+ at concentrations less than 0.3 mmol/L were within acceptable limits for both ABL800 and ABL90 inst...
PloS one, 2017
It is widespread practice during citrate anticoagulated renal replacement therapy to monitor circuit ionised calcium (iCa2+) to evaluate the effectiveness of anticoagulation. Whether the optimal site to sample the blood path is before or after the haemofilter is a common question. Using a prospectively collected observational dataset from intensive care patients receiving pre-dilution continuous veno-venous haemodiafiltration (CVVHD-F) with integrated citrate anticoagulation we compared paired samples of pre and post filter iCa2+ where the target range was 0.3-0.5 mmol.L-1 as well as concurrently collected arterial iCa2+. Two nested mixed methods linear models were fitted to the data describing post vs pre filter iCa2+, and the relationship of pre, post and arterial samples. An 11 bed general intensive care unit. 450 grouped samples from 152 time periods in seven patients on CRRT with citrate anticoagulation. The relationship of post to pre-filter iCa2+ was not 1:1 with post = 0.082...
PloS one, 2016
Regional citrate anticoagulation (RCA) during hemodialysis interferes with calcium homeostasis. Optimal ionized calcium (iCa) target range during RCA and consequent calcium balance are unknown. In a randomized controlled trial (ACTRN12613001029785) 30 chronic hemodialysis patients were assigned to normal (1.1-1.2 mmol/) or low (0.95-1.05 mmol/l) iCa target range during a single hemodialysis with RCA. The primary outcome was calcium mass balance during the procedure, using a partial spent dialysate collection method; magnesium mass balance was also measured. Intact parathormone (iPTH), total calcium (tCa) and magnesium were measured before and after procedures. Mean iCa during procedures was significantly different in the two groups (1.12±0.06 in normal and 1.06±0.07 mmol/l in low iCa group, p <0.001), resulting in different tCa (2.18±0.22 vs. 1.95±0.17, p = 0.003) after the procedure. Mean delivered calcium during the procedure was 58.3±4.8 mmol in the normal and 51.5±8.2 mmol in...
Journal of Artificial Organs, 2019
Regional citrate anticoagulation is now widely used during continuous renal replacement therapy (CRRT), and especially in patients at risk for hemorrhagic complications. A close monitoring is required to avoid citrate overload, leading to metabolic alkalosis or citrate intoxication causing metabolic acidosis. This case report describes a dysfunction of the regional citrate anticoagulation due to the development of a deep vein thrombosis close to the site of insertion of the venous CRRT catheter. The result was a local recirculation in the circuit with a local citrate overload (acidosis and non-measurable calcium). In the patient's blood samples, the [calcium total /Ca 2+ systemic ] ratio remained normal as a proof of local citrate accumulation without systemic effects. Initially, CRRT remained effective, but due to the progressive decrease of serum creatinine and cystatin C clearance, the site of catheter insertion was changed.
Clinical Journal of the American Society of Nephrology, 2008
Background and objectives: Patients who may benefit from sustained low-efficiency dialysis therapy are often at risk for bleeding. A safe and simple "regional" anticoagulation strategy would be beneficial. The modification of existing regional citrate anticoagulation protocols to typically performed 8-h sustained low-efficiency dialysis is necessary.
Regional citrate anticoagulation for hemodialysis using a conventional calcium-containing dialysate
American Journal of Kidney Diseases, 2002
Background: The majority of citrate protocols for hemodialysis (HD) use calcium (Ca)free dialysate, a limited number use dialysate with Ca, aiming to simplify the procedure. This randomized clinical study sought to compare the anticoagulant effect of citrate using Ca-free dialysate and dialysate with Ca 1.25 mmol/L. Methods: Fifty HD procedures (in 5 chronic HD patients treated by chronic citrate anticoagulation) were randomly assigned to Ca-free dialysate (25 procedures) or Ca-1.25 dialysate (25 procedures), both with Mg 0.5 mmol/L, Na 138 mmol/L, and bicarbonate 28 mmol/L. Ca-free HD: 15% Na 3 citrate 80 ml/hour was infused into the arterial line, and 1 M CaCl 2 , 14 ml/hour into the venous line. Ca-1.25 group: 15% Na 3 citrate 100 ml/hour, 1 M CaCl2 2-4 ml/hour. Polyflux H dialyzers were used. Antithrombotic effect was assessed visually after HD at 3 points: dialyzer, arterial, and venous bubble traps, using a score of 5 (no clotting) to 1 (total clotting). Results: Ca-free group: arterial bubble trap score 4.7 ± 0.5, dialyzer 4.5 ± 0.6, venous bubble trap 4.8 ± 0.6. Ionized calcium (iCa) at dialyzer inlet 0.34 ± 0.17, outlet 0.21 ± 0.06 mmol/L. All HDs were completed successfully. Ca-1.25 group: arterial bubble trap score 4.7 ± 0.5 (NS), dialyzer 2.6 ± 1.04 (p<0.01), venous bubble trap 2.4 ± 0.9 (p<0.01). Volume of clot in venous bubble trap was 1.9 ± 1.8 mL (range 0.5-6 mL). iCa at dialyzer inlet 0.24 ± 0.05 mmol/L (p<0.05), outlet 0.63 ± 0.11 mmol/L (p<0.01). Four of 25 HD procedures (16%) were prematurely terminated due to threatening dialyzer clotting, in 6/25 HD procedures (24%), the venous line was changed (p<0.01). Conclusion: Citrate anticoagulation with Ca-1.25 dialysate resulted in significantly worse anticoagulation of dialyzer and venous bubble trap compared with Ca-free dialysate, despite higher citrate dose.
Usefulness and feasibility of measuring ionized calcium in haemodialysis patients
Measuring blood calcium level is recommended in haemodialysis (HD) patients. The Kidney Disease Improving Global Outcomes position states that the measurement of ionized calcium (ICa) level is preferred, but in the clinical setting, due to technical difficulties, total calcium (tCa) level is preferred to ICa. The aim of this study was to test the possibility of delayed ICa analysis using frozen serum, and so to identify the factors associated with predialysis ICa level and compare the ability of tCa and Alb-Ca to predict ICa level and finally to compare the survival rate according to the three calcium measurements. All prevalent HD patients, dialysed by a native AV fistula in a 3 × 4 to 3 × 8 h schedule, had their predialysis ICa, tCa and Alb-Ca levels and usual mid-week biology recorded. Intergroup comparisons between ICa quartile were performed. Bland-Altman plots and linear regression were used to assess the differences between 30 fresh and frozen samples. Survival analyses were ...