Regional citrate anticoagulation for continuous renal replacement therapy in newborns and infants: Focus on citrate accumulation.

Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting the detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in the 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding the circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5), and metabolic complications. We included 10 children with mean age of 2.6 ± 3.8 months and BW of 4.6 ± 2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46 ± 9 mL/min (12 ± 5 mL/min/kg BW), citrate dose 2.8 ± 0.6 mmol/L of blood resulting in estimated citrate load to the patient of 1.7 ± 0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39 ± 29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cutoff value (sensitivity 71% and specificity 72%). CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping the blood flow below 9 mL/min/kg BW.

Citrate Extended High Cut-Off Hemodiafiltration for Renal Recovery in Patients With Multiple Myeloma.

We proposed a combination of convective and diffusive transport mechanisms as high cut-off (HCO) post-dilution hemodiafiltration dialysis technique to optimize serum immunoglobulin free light chains (FLCs) removal which may improve dialysis dependent renal failure in patients with multiple myeloma. To reduce bleeding risk regional citrate anticoagulation was successfully used for the first 7 h followed by 1 h anticoagulant-free hemodiafiltration to avoid citrate accumulation. We retrospectively assessed the effect of FLCs reduction on the renal outcome of 28 patients treated with 133 citrate extended post-dilution HCO (Theralite 2100; Gambro, Lund, Sweden) hemodiafiltration sessions between 2010 and 2016. Renal recovery was demonstrated in 61% of all patients. Twenty-three patients achieved more than 50% reduction of FLCs concentrations and 88% of those became dialysis independent. Our experience supports the extended citrate HCO hemodiafiltration as a good treatment strategy that enable a sustained reduction in serum FLCs concentration and recovery of renal function.