NDT Advance Access originally published online on October 3, 2007
Nephrology Dialysis Transplantation 2008 23(1):421-422; doi:10.1093/ndt/gfm629
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Sodium citrate anticoagulation during sustained low efficiency dialysis (SLED) in patients with acute renal failure and severely impaired liver function
Email: christian.morath{at}med.uni-heidelberg.de
Sir,
Due to severe side effects, sodium citrate anticoagulation has been avoided in patients with severely impaired liver function undergoing renal replacement therapy [1]. Based on a previously published protocol, seven patients with acute renal failure (diagnosed according to accepted guidelines) and severely impaired liver function (mean Child–Pugh score: 10.5 ± 0.5) received a total of 10 sustained low efficiency dialysis (SLED) treatments using the Genius dialysis system [2–4]. For this study, a high-flux membrane (FX 50, Fresenius Medical Care, Bad Homburg, Germany) was used. The dialysate contained 1.0 mmol/L calcium, 30 mmol/L bicarbonate and 135 mmol/L (n = 9) or 138 mmol/L (n = 1) sodium. Three percent sodium citrate (110.9 mmol/L; Fresenius Medical Care, Bad Homburg, Germany) was infused pre-filter at a rate to maintain the post-filter ionized calcium levels between 0.6 and 0.7 mmol/L. There was no routine calcium supplementation at the venous line (supplemental Figure 1). Mean patient age was 61.7 ± 4.8 years. APACHE II and SOFA score were 34.6 ± 3.4 and 16.4 ± 0.8, respectively. Laboratory values are given in Table 1. All patients were on daily dialysis before initiation of SLED therapy with sodium citrate anticoagulation. The rationale for sodium citrate anticoagulation was repeated filter clotting (filter lifetime <2 h) under heparin-free or low-dose heparin therapy. Mean dialysis time with sodium citrate anticoagulation was 17.3 ± 4.1 h. There was a mean of 0.043 ± 0.017 clotting events per h, translating to a mean (theoretical) filter lifetime of 23.3 h. No major bleeding episodes related to the dialysis therapy were observed. Total calcium, ionized calcium, calcium gap (total calcium – ionized calcium), electrolytes and base excess (as well as other parameters of acid–base balance) were maintained at stable levels during therapy and thereafter (Table 1 and supplemental Figure 2). This was also applicable in repeated SLED treatments using sodium citrate anticoagulation in the same patient. There were no significant hypotensive episodes during SLED therapy and norepinephrine dosage was significantly reduced during therapy (P < 0.04; Table 1). Our observation is in contrast with previous publications, where sodium citrate anticoagulation in patients with impaired liver function led to severe disturbances of electrolytes, acid–base haemostasis or even death [1]. The main difference between our protocol and conventional protocols is the lower sodium citrate infusion rate with higher targeted post-filter ionized calcium levels and the absence of routine calcium supplementation at the venous line. The risk of accumulating calcium-citrate complexes is further reduced by elimination of citrate complexes by high-flux dialysis [2,5]. This protocol offers the unique opportunity for sodium citrate anticoagulation in patients with even pronounced impairment of liver function. However, in the absence of serum citrate measurements and clearance determinations, accumulation of citrate complexes with longer duration of treatment or repeated treatments cannot be entirely excluded.
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1Department of Nephrology
University of Heidelberg
Heidelberg, Germany
2Clinic of Anesthesiology
University of Heidelberg
Heidelberg, Germany
3Department of Nephrology
Charité University of Berlin
Berlin, Germany
Acknowledgements
The authors would like to thank the dialysis staff (headed by Andreas Neumann) and intensive care unit staff (headed by Angelika Brobeil) at the Department of General Surgery and the Clinic of Anesthesiology at the University of Heidelberg for their support in the SLED dialysis programme.
Conflict of interest statement. None declared.
Supplementary material. Supplementary material is available at www.oxfordjournals.org.
Notes
See http://www.oxfordjournals.org/our_journals/ndtplus/
References
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[Free Full Text] - Morgera S, Scholle C, Melzer C, et al. A simple, safe and effective citrate anticoagulation protocol for the Genius dialysis system in acute renal failure. Nephron Clin Pract (2004) 98:c35–c40.[CrossRef][Web of Science][Medline]
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