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Abstract: TH-PO0422

Citrate Toxicity-Induced Tetany During High-Volume Therapeutic Plasma Exchange in Acute Liver Failure: Recognition and Prevention

Session Information

Category: Fluid, Electrolytes, and Acid-Base Disorders

  • 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Julian, Katherine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
  • Hofmeister, Elisa N, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
  • Zhang, Kathie, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
  • Bansal, Anip, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
  • Gergen, Daniel Jacob, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
  • Urra, Manuel, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
Introduction

Acute liver failure (ALF) is associated with significant morbidity and mortality. High-volume therapeutic plasma exchange (HV-TPE) has been shown to improve transplant-free survival in patients with ALF and is now recommended by multiple guidelines in the management of ALF. The use of high volumes of fresh frozen plasma in patients with ALF increases risk for citrate toxicity; however, severe adverse events were not described in initial studies. This case of citrate toxicity during HV-TPE for ALF highlights the need to revisit the unique risks associated with this procedure and for nephrologists to develop protocols to prevent severe adverse events.

Case Description

Here we report the case of a 31-year-old female with alcohol use disorder who presented with acute liver injury that quickly progressed to acute liver failure. She was treated with high-volume therapeutic plasma exchange but developed tetany resulting in broken teeth and vasopressor-dependent shock. She was found to have severe hypocalcemia due to citrate toxicity. The next HV-TPE treatment was split into two sessions, interjected by renal replacement therapy (table 1). Severe hypocalcemia was avoided and hemodynamic stability maintained.

Discussion

HV-TPE is increasingly used as a part of guideline-directed therapy for ALF. Severe hypocalcemia from citrate toxicity is an under-recognized severe adverse event that can occur during HV-TPE in ALF. Minimizing the risk of this is essential to safely performing this procedure and could involve dividing HV-TPE into multiple sessions and increasing calcium replacement beyond standard protocols.

Table 1
 HV-TPE 1 HV-TPE 2A HV-TPE 2B
Treatment 15% IBW exchange- 7.5 L FFP
4mL 10% CaCl2 per liter replacement fluid
Plasma Removed (L): 7.614
Replacement Fluid (L): 7.500
8% IBW exchange- 4 L FFP
10mL 10% CaCl2 per liter replacement fluid
Plasma Removed (L): 4.124
Replacement Fluid (L): 3.980
7% IBW exchange-3.5 L FFP
10mL 10% CaCl2 per liter replacement fluid
Plasma Removed (L): 3.620
Replacement Fluid (L): 3.500
Post-treatment BP: 98/63, T: 36.4, RR: 34, HR: 128 BP: 99/59, T: 37.1, RR: 13, HR:104 BP: 141/60, T: 36.9, RR: 15, HR:113
Total Calcium (mg/dL) 7.8, 10.4, 10.4 8.9, 11.4, 12.9 11.4, 13.2, 12.4
Ionized Calcium (mmol/L) 1.07, 1.32, 0.42 1.21, 1.01, 1.26 1.27, 1.09, 1.28

Digital Object Identifier (DOI)