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. 2017 Nov 29;21(1):294.
doi: 10.1186/s13054-017-1870-3.

Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction

Matthias Klingele  1   2   3 , Theresa Stadler  4 , Danilo Fliser  4 , Timo Speer  4 , Heinrich V Groesdonk  5 , Alexander Raddatz  5
Affiliations

Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction

Matthias Klingele et al. Crit Care. .

Abstract

Background: As of 2009, anticoagulation with citrate was standard practice in continuous renal replacement therapy (CRRT) for critically ill patients at the University Medical Centre of Saarland, Germany. Partial hepatic metabolism of citrate means accumulation may occur during CRRT in critically ill patients with impaired liver function. The aim of this study was to evaluate the actual influence of hepatic function on citrate-associated complications during long-term CRRT.

Methods: In a retrospective study conducted between January 2009 and November 2012, all cases of dialysis therapy performed in the interdisciplinary surgical intensive care unit were analysed. Inclusion criteria were CRRT and regional anticoagulation with citrate, pronounced liver dysfunction, and pathologically reduced indocyanine green plasma disappearance rate (ICG-PDR).

Results: A total of 1339 CRRTs were performed in 69 critically ill patients with liver failure. At admission, the mean Model for End-stage Liver Disease score was 19.2, and the mean ICG-PDR was 9.8%. Eight patients were treated with liver replacement therapy, and 30 underwent transplants. The mortality rate was 40%. The mean duration of dialysis was 19.4 days, and the circuit patency was 62.2 h. Accumulation of citrate was detected indirectly by total serum calcium/ionised serum calcium (tCa/iCa) ratio > 2.4. This was noted in 16 patients (23.2%). Dialysis had not to be discontinued for metabolic disorder or accumulation of citrate in any case. In 26% of cases, metabolic alkalosis occurred with pH > 7.5. Interestingly, no correlation between citrate accumulation and liver function parameters was detected. Moreover, most standard laboratory liver function parameters showed poor predictive capabilities for accumulation of citrate.

Conclusions: Our findings indicate that extra-hepatic metabolism of citrate seems to exist, avoiding in most cases citrate accumulation in critically ill patients despite impaired liver function. Because the citric acid cycle is oxygen-dependent, disturbed microcirculation would result in inadequate citrate metabolism. Raising the tCa/iCa ratio would therefore be an indicator of severity of illness and mortality rather than of liver failure. However, further studies are warranted for confirmation.

Keywords: Accumulation; Anticoagulation; CRRT; Citrate; Critically ill; Liver.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable; see the Methods section of the main text.

Consent for publication

Not applicable; see the Methods section of the main text.

Competing interests

MK received speaker fees from Baxter, Fresenius Medical Care and Cytosorbents, DF received honoraria from Fresenius Medical Care. The other authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Flowchart displaying the study population
Fig. 2
Fig. 2
The occurrence of metabolic complications in this study compared with what would have been expected in patients with impaired liver function undergoing continuous renal replacement therapy with regional citrate anticoagulation. CVVHD Continuous venovenous haemodialysis; ICG-PDR Indocyanine green plasma disappearance rate
See this image and copyright information in PMC

Comment in

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