Sodium citrate versus sodium bicarbonate for metabolic acidosis in patients with chronic kidney disease: A randomized controlled trial.

BACKGROUND: Metabolic acidosis (MA) is frequently associated with chronic kidney disease (CKD) progression. Our aim was to compare the effect of oral sodium citrate (SC) with that of oral sodium bicarbonate (SB) on renal function and serum bicarbonate correction, as well as to evaluate their safety profile in patients with MA of CKD. METHODS: We conducted a prospective, single-center, randomized 1:1, parallel, controlled, unblinded clinical trial of 124 patients with MA and CKD stages 3b and 4. The primary outcome was the mean change in estimated glomerular filtration rate (eGFR). The secondary outcomes were mean change in serum bicarbonate level, eGFR decrease by 30%, eGFR decrease by 50%, dialysis, death or prolonged hospitalization, and a combined endpoint. RESULTS: No significant difference was found between the groups in terms of mean eGFR change [adjusted mean difference = -0.99 mL/min/1.73 m2 (95% CI: -2.51 to 0.93, P = .20)]. We observed a mean serum bicarbonate change of 6.15 mmol/L [(95% CI: 5.55-6.74), P < .001] in the SC group and of 6.19 mmol/L [(95% CI: 5.54-6.83), P < .001] in the SB group, but no significant difference between the 2 groups [adjusted mean difference = 0.31 mmol/L (-0.22 to 0.85), P = .25]. Cox proportional hazard analysis showed similar risks regarding eGFR decrease by 30% (P = .77), eGFR decrease by 50% (P = .50), dialysis (P = .85), death or prolonged hospitalization (P = .29), and combined endpoint (P = .57). Study drug discontinuation due to adverse events was significantly more common in the SB group (17.7% vs 4.8%, P = .02). CONCLUSIONS: SC and SB have a similar effect on kidney function decline, both improve serum bicarbonate level, but SB is associated with higher rates of medication discontinuation due to adverse events.

Decision-Making Error in Platelet Transfusion Caused by EDTA-Dependent Pseudothrombocytopenia: a Case Report and Literature Review.

BACKGROUND: Ethylenediaminetetraacetic acid-dependent pseudothrombocytopenia (EDTA-PTCP) is a rare phenomenon characterized by pseudo low platelet counts when using EDTA as anticoagulant and can result in false decision making of platelet transfusion. METHODS: An application for platelet transfusion from a patient who planned to undergo spinal surgery was received by the Department of Transfusion service. The preoperative laboratory test results showed thrombocytopenia (platelet counts: 27 x 109/L). The surgeon planned to transfuse platelets before the operation to avoid bleeding in operation due to thrombocytopenia. However, the lab technologist found that there was aggregation of platelets under the microscope. Samples used with sodium citrate and heparin as anticoagulants were rechecked. RESULTS: The platelet count of the patient was normal in sodium citrate and heparin anticoagulant tubes. The patient had no history and clinical symptoms of thrombocytopenia. Therefore, the doctor canceled the platelet order. We also reviewed the relevant literature of EDTA-PTCP. CONCLUSIONS: EDTA-PTCP is rare and may result of a wrong decision of platelet transfusion. Correct understanding and treatment of this situation can avoid unnecessary platelet transfusion.

Different platelet-rich plasma preparation protocols in Female pattern hair loss: Does it affect the outcome? A pilot study.

BACKGROUND: Platelet-rich plasma (PRP) injection is a promising modality for hair regeneration in female pattern hair loss (FPHL). A standard protocol on best methods for PRP preparation has not been established. OBJECTIVES: To optimize standard PRP preparation protocols and evaluate its clinical efficacy in FPHL. METHODS: Comparative study enrolled 40 female patients with FPHL divided randomly into 4 equal groups. Each group received 3 sessions of monthly intradermal injection of PRP prepared by different methods regarding number of spins, centrifugation speeds, type of the centrifuge, and the size of PRP tube. Patients were evaluated by trichoscan before and 1 month after the 3rd session for number of terminal, vellus hair, and average hair width. RESULTS: A statistically significant increase in platelet count in PRP prepared by combination of digital centrifuge, large-sized sodium citrate tube, and low centrifugation speed (900 rpm). All patients showed statistically significant increase in percentage of terminal hair and average width of hair after treatment as assessed by trichoscan, without statistically significant difference between studied groups. CONCLUSIONS: Digital centrifuge, large-sized sodium citrate tubes, and a single spin with low centrifugation speed (900 rpm) were ideal for PRP preparation. PRP is an effective and safe modality in FPHL therapy.

Does alkalinised urine reduce the rate of encrustation in patients with ureteric stents? A randomised controlled study.

PURPOSE: Stent encrustation is not uncommonly encountered with a high number of ureteric stents. The exact pathophysiology is not well understood. Therefore, we investigated the relationship between the use of sodium citrate and likelihood of stent encrustation. METHODS: This prospective, randomised, intervention study was conducted between October 2018 and October 2019 in a tertiary hospital. Overall, 115 patients with ureteral stents that were inserted after lithotripsy surgeries were recruited. The study subjects were randomised into two groups: one group was administered sodium citrate (Utix sachets) three times per day until stent removal (intervention group), and the second group was not administered Utix sachets (control group). Stents were removed after 1 month and inspected under macroscopic visualisation from the proximal to distal end for any crystallisation; a second inspection was done with a 60 × magnification lens. Any crystallisation observed was considered to be encrustation. RESULTS: Patients who had Utix sachets post-insertion of a ureteric stent constituted 50.4% of the study cohort. The rate of encrustation in the control group was 52.6%. In the intervention group, the rate of encrustation was 46.6%. The difference was not statistically significant with the chi-squared test (p value, 0.514). CONCLUSION: Alkaline citrate medications had no significant effect on stent encrustation rate. More studies are needed to elucidate different agents and their roles in reducing stent encrustation as it incurs high morbidity.

Intranasal sodium citrate in quantitative and qualitative olfactory dysfunction: results from a prospective, controlled trial of prolonged use in 60 patients.

OBJECTIVES: We have previously shown that treatment with intranasal sodium citrate may be beneficial in post-infectious olfactory dysfunction. Sodium citrate reduces free intranasal calcium and is, therefore, thought to prevent calcium-mediated feedback inhibition at the level of the olfactory receptor. We aimed to determine whether treatment with a 2-week course of intranasal sodium citrate improves quantitative olfactory function in patients with post-infectious impairment. We also aimed to determine whether sodium citrate is beneficial in treating qualitative olfactory dysfunction. METHODS: We performed a prospective, controlled study. Patients applied intranasal sodium citrate solution to the right nasal cavity for 2 weeks. The left nasal cavity was untreated and, therefore, acted as an internal control. Monorhinal olfactory function was assessed using the "Sniffin' Sticks" composite 'TDI' score, before and after treatment. The presence of parosmia and phantosmia was also assessed. RESULTS: Overall, there was a significant increase in TDI after treatment (using the best of right and left sides). Treatment with sodium citrate did not significantly improve quantitative olfactory function, compared to control. The proportion of patients reporting parosmia did not change significantly after treatment. However, there was a significant reduction in the proportion of patients reporting phantosmia, at the end of the study period. CONCLUSIONS: Treatment with intranasal sodium citrate for a period of 2 weeks does not appear to improve quantitative olfactory function in patients with post-infectious impairment, compared to control. It may, however, be beneficial in treating phantosmia, which should be further addressed in future work.

Prevention of Contrast-induced Nephropathy in Patients with Chronic Kidney Disease Undergoing Elective Coronary Angioplasty or Angiography with Sodium Potassium Citrate Solution, a Double Blind Randomized Clinical Trial.

INTRODUCTION: Contrast-induced nephropathy (CIN) is a frequent complication of contrast exposure. A recent study suggested that Na/K citrate might have a preventive role. We investigated the efficacy of Na/K citrate to prevent CIN in patients with renal dysfunction undergoing coronary intervention. METHODS: The randomized, double-blind, placebo-controlled trial included 201 patients with estimated creatinine clearance < 90 mL/ min, randomized to receive oral Na/K citrate plus saline infusion (treatment group, 104 patients) or oral water plus saline infusion (placebo group, 97 patients). CIN was defined as an absolute increase of serum creatinine ≥ 0.5 mg/dL or a relative increase ≥ 25% or a relative decrease of estimated GFR ≥ 25% within 5 days. RESULTS: CIN occurred in 22 patients (12.29%); 10 (11%) in treatment group and 12 (13.6%) in placebo group (P > .05). Post-exposure Cr values were not significantly different between the two groups (1.18 ± 0.28 mg/dL in the placebo vs. 1.15 ± 0.29 mg/dL in the treatment group, P > .05). CIN-negative patients in the treatment group showed a significantly higher increase in urine pH than that of CIN-positive patients (1.642 ± 0.577 vs. 1.20 ± 0.422, P < .05). CONCLUSION: Na/K citrate solution is not effective for prophylaxis of CIN in patients with renal dysfunction. However, a probable preventive effect might exist in a subgroup of patients with at least 1.6 units increase in urine pH values following Na/K citrate administration.

[A case of severe metformin-associated lactic acidosis treated with CVVHDF and regional anticoagulation with sodium citrate].

Metformin is an antidiabetic drug; used to treat type II diabetes mellitus, metformin associated lactic acidosis has an incidence of 2-9 cases / 100,000 patients / year with high mortality (30%). We have had the case of a 75-year-old woman with metabolic acidosis as a result of metformin assumption, treated by renal replacement therapy (CRRT) with continuous veno-venous hemodiafiltration (CVVHDF). RESULTS: after a short treatment period there was a reduction in Lactates (from 16.8 mmol/L to 12.6 mmol/L) and a progressive improvement of acidosis. In 72 hours the recovery of diuresis and subsequent suspension of CRRT was achieved. CONCLUSION: CRRT, in addition to ensuring support for renal failure and volume correction, allowed a rapid recovery from metformin-associated lactic acidosis.

A randomized controlled clinical trial of 4% sodium citrate versus heparin as locking solution for temporary dialysis catheters among hemodialysis patients
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BACKGROUND: Limited reports are available on the role of 4% citrate as a locking solution for temporary dialysis catheters. Hence, the aim of this study is to investigate the role of 4% citrate vs. heparin 5,000 µ/mL as a catheter-locking solution in a randomized controlled trial. MATERIALS AND METHODS: The trial was conducted in Egypt where the use of non-tunneled temporary catheters is prevalent compared to tunneled long-term catheters. The efficacy of catheter-locking solutions was compared regarding observation of rate of catheter dysfunction, low-flow pump, fever as a sign of central-line blood-stream infection (CLBSI), catheter-site infection, thrombosis, local bleeding, and systemic bleeding in each group of the study. RESULTS: Each group consisted of 105 patients. The number of patients who developed CLBSI in the citrate group was 11 (10.5%) compared to 23 (21.9%) in the heparin group (p < 0.025). The number of patients who developed catheter dysfunction in the citrate group was similar to those in the heparin group. The incidence of catheter-site infection, thrombosis, and local bleeding in the citrate group was similar to that in the heparin group. CONCLUSION: Citrate 4% lock solution is equally effective as heparin in maintaining catheter patency in dialysis patients. It may have a favorable effect on prevention of catheter-related infection due to its additional antiseptic properties as compared to heparin. Citrate-based locking solutions are a promising alternative to unfractionated heparin as a locking solution for dialysis catheters.
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Effects of sodium citrate, citric acid and lactic acid on human blood coagulation.

INTRODUCTION: Citric acid infusion in extracorporeal blood may allow concurrent regional anticoagulation and enhancement of extracorporeal CO2 removal. Effects of citric acid on human blood thromboelastography and aggregometry have never been tested before. METHODS: In this in vitro study, citric acid, sodium citrate and lactic acid were added to venous blood from seven healthy donors, obtaining concentrations of 9 mEq/L, 12 mEq/L and 15 mEq/L. We measured gas analyses, ionized calcium (iCa++) concentration, activated clotting time (ACT), thromboelastography and multiplate aggregometry. Repeated measure analysis of variance was used to compare the acidifying and anticoagulant properties of the three compounds. RESULTS: Sodium citrate did not affect the blood gas analysis. Increasing doses of citric and lactic acid progressively reduced pH and HCO3- and increased pCO2 (p<0.001). Sodium citrate and citric acid similarly reduced iCa++, from 0.39 (0.36-0.39) and 0.35 (0.33-0.36) mmol/L, respectively, at 9 mEq/L to 0.20 (0.20-0.21) and 0.21 (0.20-0.23) mmol/L at 15 mEq/L (p<0.001). Lactic acid did not affect iCa++ (p=0.07). Sodium citrate and citric acid similarly incremented the ACT, from 234 (208-296) and 202 (178-238) sec, respectively, at 9 mEq/L, to >600 sec at 15 mEq/L (p<0.001). Lactic acid did not affect the ACT values (p=0.486). Sodium citrate and citric acid similarly incremented R-time and reduced α-angle and maximum amplitude (MA) (p<0.001), leading to flat-line thromboelastograms at 15 mEq/L. Platelet aggregometry was not altered by any of the three compounds. CONCLUSIONS: Citric acid infusions determine acidification and anticoagulation of blood similar to lactic acid and sodium citrate, respectively.

Regional citrate anticoagulation in membrane based plasma exchange: Safety, efficacy and effect on calcium balance.

AIM: To assess the efficacy, safety and calcium balance of a membrane based regional citrate anticoagulation plasma exchange protocol. METHODS: This was an observational, prospective, single centre study of membrane separation plasma exchange using regional citrate anticoagulation. It was performed using a fixed dose pre-filter citrate infusion that was based on the plasma flow rate. Patients received a post filter calcium infusion that was modified during treatment based on systemic ionized calcium monitoring. Post filter ionized calcium was not assessed. Safety and efficacy were assessed by extraction of clinical events and laboratory data contemporaneously recorded in electronic health records. RESULTS: Thirty-six sessions in five patients were performed. No patients developed symptomatic hypocalcaemia, and no patient had a recorded ionized calcium below 0.81 mmol/L. Filter clotting occurred in two sessions. The mean net calcium gained was 9.6 ± 1.8 mmol per session. CONCLUSION: Regional citrate anticoagulated membrane separation plasma exchange can be performed safely and effectively without the need for post filter ionized calcium monitoring. The algorithm employed resulted in a net calcium gain.

Potassium-sodium citrate prevents the development of renal microcalculi into symptomatic stones in calcium stone-forming patients.

OBJECTIVES: To evaluate the effect of potassium-sodium citrate on the development of computed tomography-detected renal microcalculi into symptomatic stones in calcium stone-forming patients. METHODS: Patients (aged 20-80 years) with history of calcium component stones who visited Nagoya City Hospital, Nagoya, Aichi, Japan, between April 2009 and June 2014 were included. They were retrospectively divided into those who did not receive potassium-sodium citrate (non-citrate group, n = 157) and those who did (citrate group, n = 60). For patients in both groups, we evaluated blood and urine biochemistry and sediment, number of computed tomography-detected microcalculi, number of asymptomatic microcalculi disappearances, and pain events. Observations were made at study initiation and 12 months later. RESULTS: The citrate group showed a significantly increased urine pH (P < 0.001) and daily citrate excretion (P < 0.001) over the study period. The non-citrate group showed increased numbers of microcalculi at study completion (P = 0.002); over the same period, the number of microcalculi in the citrate group decreased significantly (P = 0.03). Additionally, multivariable analysis showed more asymptomatic microcalculi disappearances (odds ratio 2.84, 95% confidence interval 1.49-5.39) and fewer pain events (odds ratio 0.37, 95% confidence interval 0.16-0.72) in the citrate group than in the non-citrate group. A sex-adjusted analysis showed more asymptomatic microcalculi disappearances (odds ratio 3.96, 95% confidence interval 1.57-10.02) and fewer pain events (odds ratio 0.22, 95% confidence interval 0.07-0.70) in women than in men after citrate treatment. CONCLUSIONS: Potassium-sodium citrate prevents the development of renal microcalculi into symptomatic stones in calcium stone-forming individuals.