Treatment Efficacy and Safety During Plasma Exchange With Citrate Anticoagulation: A Randomized Study of 4 Versus 15% Citrate

Abstract

In plasma exchange (PE), contrary to dialysis, there is no ultrafiltration, and the volume of anticoagulant contributes to volume overload of the patient and might also reduce PE efficiency through dilution. To reduce the volume of citrate, we compared 4 and 15% citrate anticoagulation protocols in PE in a randomized study, aiming to evaluate PE efficacy, anticoagulation efficiency, and overall safety. In addition to standard biochemical analyses during PE treatments, the elimination rate (ER) of immunoglobulins was calculated to evaluate PE efficacy. Anticoagulation was evaluated by postfilter ionized calcium, visual evaluation of the extracorporeal system, and change in the sieving coefficient (SC) during PE. Accumulation of citrate was determined by calculating the total-to-ionized calcium ratio and measuring the citrate concentration after PE. One hundred forty procedures (70 in each group) were performed in 37 patients. The mean citrate infusion rate was 197±10 mL/h in the 4% and 59±5.5 mL/h in the 15% groups, respectively; the total volume of infused citrate was 502±77 mL versus 164±52 mL (P<0.001). ER for immunoglobulin G (0.57±0.06 vs. 0.55±0.1, P=0.18), M, and A were comparable. Ionized calcium was stable during the procedures, and there were no significant side effects. Although postfilter ionized calcium was on the upper limit of the target range (0.41±0.16 vs. 0.37±0.14mmol/L, P=0.38), the visual assessment score was excellent, and even a rise in SC was observed during the procedures in both groups. The total-to-ionized calcium ratio was increased in 20 versus 22% of procedures, and citrate concentrations after PE were also similar (1306±441 vs. 1263±405μmol/L). To conclude, we were unable to show superior PE efficacy in the 15% citrate group, but we significantly reduced the infused volume, which is important in patients with fluid overload. Both citrate protocols were found to provide excellent anticoagulation without significant metabolic disturbances or other side effects, confirming the safety of 15% citrate as anticoagulant during PE.