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Abstract: TH-PO361

A Novel Post-Dilution CVVHDF-RCA with Personalized Initial Calcium Dosing and Fixed Citrate to Blood Flow Ratio

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Yessayan, Lenar Tatios, University of Michigan, Ann Arbor, Michigan, United States
  • Heung, Michael, University of Michigan, Ann Arbor, Michigan, United States
  • Sohaney, Ryann, University of Michigan, Ann Arbor, Michigan, United States
  • Puri, Vidhit, University of Michigan, Ann Arbor, Michigan, United States
  • Wagner, Benjamin, University of Michigan, Ann Arbor, Michigan, United States
  • Szamosfalvi, Balazs, University of Michigan, Ann Arbor, Michigan, United States
Background

Regional citrate anticoagulation (RCA) use is limited by concerns of electrolyte complications. We describe a novel approach for post-dilution CVVHDF that minimizes nurse workload, achieves desired circuit anticoagulant activity, and avoids life-threatening hypocalcemia even in patients with fulminant liver failure.

Methods

Post-dilution CVVHDF was performed using Prismaflex machines at one of three blood flow rates 60, 100, or 150ml/min based on patient’s body weight. Acid citrate dextrose-A solution (113 mmol/L) was infused into the arterial limb of the extracorporeal circuit at one of three rates 150, 250, 300 ml/h depending on blood flow rate. Equal dialysate/replacement flow rates are determined from a table according to body weight (for 25-30 ml/kg/h total effluent) in those with expected normal citrate metabolism and modified according to weight and circuit plasma flow in those with absent citrate metabolism. Dialysate/replacement fluid electrolyte concentrations were as follows: Na 136-151, K 2-4, Ca 0, and HCO3 25-45 mEq/L, phosphate 0 to 1.36 mmol/L. Initial calcium chloride solution (136 mmol/L) infusion rate was determined according to a dosing table based on effluent rate and daily serum albumin and titrated thereafter according to systemic ionized calcium (iCa) every 6 hours. Circuit iCa was obtained every 12 hours. RCA effectiveness was measured in terms of circuit iCa and filter life. Electrolyte trends for 30 consecutive patients are reported.

Results

The protocol achieves adequate circuit anticoagulation (circuit iCa <0.4 mM in >95% of measured samples). The risk of clinically significant hypocalcemia is less than 1%. The risk of hypernatremia or metabolic alkalosis is abrogated. Clinically significant hypophosphatemia is avoided by spiking commercial solutions with sodium or potassium phosphate.

Conclusion

The approach achieves desired circuit anticoagulant activity, avoids life-threatening hypocalcemia and poses no risks related to RCA.