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Abstract: TH-PO508

Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy in Children: Opportunities for Optimization

Session Information

  • Pediatric Nephrology - I
    November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Pediatric Nephrology

  • 1900 Pediatric Nephrology

Authors

  • Santana, Danilo, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
  • Ortega, Caroline Sartori, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
  • Nóbrega, Lilian Caroline da Silva, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
  • Luglio, Michele, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
  • Watanabe, Andreia, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
  • Carvalho, Werther Brunow de, Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
Background

Regional citrate anticoagulation (RCA) is based on blood citrate concentration of 3-4 mmol/L to reach post filter ionized calcium (Cai) of 0,25-0,40 mmol/L in continuous hemodiafiltration (CVVHDF). However, it can lead to metabolic complications of citrate accumulation.

Methods

From May 2019 to Dec 2022, 5,5% (109/1970) of patients admitted in a PICU were submitted to CVVHDF using RCA with 2,2% citrate. 25 patients were excluded for CVVHDF <24h, and 3 others for prior CVVHDF. Data related to minimum magnesemia was analyzed to sensitize the results.

Results

From the 81 patients included, 56,8% were girls, the age was 4.2 years (1.1-12.8) and the weight 13 kg (8,1-36,3). Organic dysfunctions were cardiovascular in 64,2%, pulmonary in 70,4% and hepatic in 65,4%, and the mortality rate was 51.9%. Hypomagnesemia (Mg<1,7mg/dL) was observed in 64% of patients, and the minimum magnesemia was 1,6mg/dL (1,4-1,8), where blood flow rate was 6ml/kg/min (3,4-7,5), the replacement+dialisate fluid rate of 65 ml/kg/h (47-92), blood citrate concentration of 1,7 mmol/L (1,4-2,6), citrate dosage of 0,6mmol/kg/h (0,35-0,85), reaching CaT/Cai (citrate GAP) of 2,01 (1,89-2,03). Only 4 patients presented citrate acummulation (citrate GAP >2,5). Patients <1 years of age reached larger blood flow rate [7,7 (6,7-11,7) vs 4,8 (3-6,5), p<0,001], smaller blood citrate concentration [1,5 (1,4-1,9) vs 1,9 (1,4-2,80), p=0,048], larger citrate dosage [0,75 (0,64-1,09) vs 0,53 (0,32-0,77), p=0,008], and larger citrate GAP [2,14 (1,96-2,33) vs 1,96 (1,79-2,09), p=0,035]. Blood citrate concentration tended to be smaller in the circuits with <36 horas of duration (48,7%), [1,7mmol/L (1,3-2,0) vs 1,9 (1,4-2,8) vs p=0,062], and no difference was observed in the citrate dose (p=0,117) or post filter Cai (p=0,385).

Conclusion

The low circuit patency obtained is probably associated with the low blood citrate concentration used. Children <1 year of age presented good tolerance to high doses of citrate, with a low rate of citrate accumulation. It is possible that children tolerate citrate dosages of 0,6-0,85 mmol/kg/h, reaching blood citrate concentration of 3mmol/L by adjusting the blood flow rate to 2-5 ml/kg/min, improving circuits patency without major metabolic consequences.