Regional citrate anticoagulation for PrismaFlex continuous renal replacement therapy.

BACKGROUND: Since Mehta et al. reported the first successful use of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) in 1990, RCA is increasingly used for CRRT because it provides filter patency with minimal risk of bleeding. However, RCA has been associated with significant metabolic complications including hypocalcemia, hypernatremia, metabolic alkalosis, and citrate toxicity. OBJECTIVE: To describe our experience with a newly implemented RCA protocol with acid citrate dextrose formula A (ACD-A) and intravenous calcium gluconate, for use with PrismaFlex CRRT in critically ill patients with acute kidney injury. METHODS: A retrospective chart review was conducted from May 1, 2006, until May 1, 2007, in a 16-bed medical-surgical university-affiliated intensive care unit. Data collected included dialysis filter life, patient and circuit metabolic parameters, and units of packed red blood cells transfused. RESULTS: Forty-eight patients received dialysis with citrate (n = 178 filters). Circuit clotting occurred in 24% of all filters. Mean +/- SD filter life was 38.4 +/- 25.9 hours, and filter survival at 48 hours was 38.2%. Persistent metabolic alkalosis while on CRRT was identified in 6 of 45 (13.3%) patients. Mild hypocalcemia (ionized calcium <3.6 mg/dL) occurred in 11 (23%) patients, but no patient had an ionized calcium level less than 2.8 mg/dL. Six patients, 3 with acute leukemia, required transfusion of 2 or more units of packed red blood cells in 24 hours. CONCLUSIONS: We found that anticoagulation of PrismaFlex CRRT with ACD-A and intravenous calcium gluconate provided reasonable filter patency, but with minor metabolic complications. Close monitoring of electrolyte and acid-base balance is required to minimize metabolic derangements.

Management of severe hyperkalemia without hemodialysis: case report and literature review.

PURPOSE: To report a case of severe hyperkalemia successfully managed without the use of hemodialysis and to provide a review of the literature regarding the management of severe hyperkalemia. METHODS: A clinical case report from the medical-surgical intensive care unit of a teaching hospital and a literature review are presented. The case involves a 59-year old man with diabetes mellitus, essential hypertension, and gout, who presented to hospital with severe hyperkalemia (K(+) = 10.4 mEq/L) and normal renal function. He was treated with intravenous fluids, sodium bicarbonate, calcium chloride, insulin, calcium resonium, and furosemide. RESULTS: The hyperkalemia resolved with conservative treatment within 8 hours, and dialytic therapy was not required. The literature review supported an initial conservative management approach in stable patients with intact renal function. CONCLUSIONS: Hemodialysis is not necessary for all cases of severe hyperkalemia and should be reserved for patients with acute or chronic renal failure or those with life-threatening hyperkalemia unresponsive to more conservative measures.