CLINICAL ACUTE KIDNEY INJURY 1

Abstract

Introduction and Aims: As of 2009, anticoagulation with citrate has been standard practice for all continuous renal replacement therapy (CRRT) in critically ill patients at the University Medical Centre of Saarland, Germany. Data concerning citrate anticoagulation in CRRT for critically ill patients with deranged liver function are sparse and inconsistent. The aim of the current study was to analyse complications from citrate anticoagulation in case of liver failure. Method(s): Between 01/2009 and 11/2012 a total of 1339 dialysis were performed in 69 critically ill patients with liver failure during their stay in the interdisciplinary surgical intensive care unit (ICU). Most patients had pre-existing liver diseases. In 8 patients liver replacement therapy was performed. 30 patients received liver transplantation. Mean maximal SAPS Score was 56.2 and MELD 29.8 at dialysis initiation. Result(s): Mean dialysis period was 19.4 days (+/-22.9; 1-105). Adequate anticoagulation was achieved with 4.0mmol citrate per litre of blood resulting in an extracorporeal ionised calcium of 0,3mmol/l and a mean circuit lifetime of 62.2 hours (+/-11.2; 24.0-80.0). Mean patient serum level of ionised and total calcium (iCa and tCa) were 1.14 (+/-0.08; 0.95-1.40) and 2.52 (+/-0.17; 2.00-3.02) respectively. A standard blood flow of 100ml/min and dialysis flow of 2000ml/h was applied in 48.5% of dialysis. Signs of citrate accumulation with a ratio of iCa/tCa above 2.4 were noted in 16 patients. Reduction of blood flow and increased dialysate flow resulted in normalised iCa/tCa ratio within 24 hours. Effective dialysis dose was 28.9ml/h/kg (+/-8.5; 12.1-70.3).A tCa above 2.7mmol/l was noted in 9 patients. However conversion from citrate to heparine was only required in one patient for three days due to insufficient reduction in citrate accumulation. No patient displayed clinical signs of hypercalcemia. Conclusion(s): Anticoagulation with citrate for dialysis in critically ill patients with severe liver dysfunction led to accumulation in less than 50% of cases. Citrate accumulation can easily be managed with adequate titration of dialysis dose.