Safety and efficacy of regional citrate anticoagulation in continuous venovenous hemodialysis in the presence of liver failure: the Liver Citrate Anticoagulation Threshold (L-CAT) observational study

Critical Care - 2015
Torsten Slowinski1, Stanislao Morgera1, Michael Joannidis2, Thomas Henneberg3, Reto Stocker4, Elin Helset5, Kirsti Andersson6, Markus Wehner7, Justyna Kozik-Jaromin8, Sarah Brett9, Julia Hasslacher2, John F. Stover4, Harm Peters1, Hans-H. Neumayer1, Detlef Kindgen-Milles9
1Department of Nephrology, University Hospital Charité, Campus Mitte (CCM), Berlin, Germany
2Divison of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
3Department of Visceral and Transplant Surgery, University Hospital Charité, CVK, Berlin, Germany
4Surgical Intensive Care, University Hospital Zurich, Zurich, Switzerland
5Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
6Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.
7Department of Anesthesiology, Leipzig University Hospital, Leipzig, Germany
8Clinical Research, Fresenius Medical Care, Bad Homburg, Germany
9Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany

Tóm tắt

Regional citrate anticoagulation (RCA) for continuous renal replacement therapy is widely used in intensive care units (ICUs). However, concern exists about the safety of citrate in patients with liver failure (LF). The aim of this study was to evaluate safety and efficacy of RCA in ICU patients with varying degrees of impaired liver function. In a multicenter, prospective, observational study, 133 patients who were treated with RCA and continuous venovenous hemodialysis (RCA-CVVHD) were included. Endpoints for safety were severe acidosis or alkalosis (pH ≤7.2 or ≥7.55, respectively) and severe hypo- or hypercalcemia (ionized calcium ≤0.9 or ≥1.5 mmol/L, respectively) of any cause. The endpoint for efficacy was filter lifetime. For analysis, patients were stratified into three predefined liver function or LF groups according to their baseline serum bilirubin level (normal liver function ≤2 mg/dl, mild LF >2 to ≤7 mg/dl, severe LF >7 mg/dl). We included 48 patients with normal liver function, 43 with mild LF, and 42 with severe LF. LF was predominantly due to ischemia (39 %) or multiple organ dysfunction syndrome (27 %). The frequency of safety endpoints in the three patient strata did not differ: severe alkalosis (normal liver function 2 %, mild LF 0 %, severe LF 5 %; p = 0.41), severe acidosis (normal liver function 13 %, mild LF 16 %, severe LF 14 %; p = 0.95), severe hypocalcemia (normal liver function 8 %, mild LF 14 %, severe LF 12 %; p = 0.70), and severe hypercalcemia (0 % in all strata). Only three patients showed signs of impaired citrate metabolism. Overall filter patency was 49 % at 72 h. After censoring for stop of the treatment due to non-clotting causes, estimated 72-h filter survival was 96 %. RCA-CVVHD can be safely used in patients with LF. The technique yields excellent filter patency and thus can be recommended as first-line anticoagulation for the majority of ICU patients. ISRCTN Registry identifier: ISRCTN92716512 . Date assigned: 4 December 2008.

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