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Observational Study
. 2015 Sep 29:19:349.
doi: 10.1186/s13054-015-1066-7.

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

Torsten Slowinski  1 , Stanislao Morgera  2 , Michael Joannidis  3 , Thomas Henneberg  4 , Reto Stocker  5 , Elin Helset  6 , Kirsti Andersson  7 , Markus Wehner  8 , Justyna Kozik-Jaromin  9 , Sarah Brett  10 , Julia Hasslacher  11 , John F Stover  12 , Harm Peters  13 , Hans-H Neumayer  14 , Detlef Kindgen-Milles  15
Affiliations
Observational Study

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

Torsten Slowinski et al. Crit Care. .

Abstract

Introduction: 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.

Methods: 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).

Results: 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 %.

Conclusions: 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.

Trial registration: ISRCTN Registry identifier: ISRCTN92716512 . Date assigned: 4 December 2008.

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Figures

Fig. 1
Fig. 1
Survival probability of filters of regional citrate anticoagulation and continuous venovenous hemodialysis (RCA-CVVHD) circuits. Continuous line: all filter discontinuations. Dashed line: Clotting only (i.e., censored for non-clotting events)
Fig. 2
Fig. 2
Estimated mean ± standard deviation of arterial pH and serum bicarbonate concentrations during regional citrate anticoagulation and continuous venovenous hemodialysis according to liver groups
Fig. 3
Fig. 3
Estimated mean ± standard deviation of blood flow to dialysate flow during regional citrate anticoagulation and continuous venovenous hemodialysis according to liver groups
Fig. 4
Fig. 4
Estimated mean ± standard deviation of systemic arterial ionized calcium (iCa) and calcium dose during regional citrate anticoagulation and continuous venovenous hemodialysis according to group
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