Abstract
Patients with liver failure may suffer citrate accumulation when using regional citrate anticoagulation for artificial liver support system therapy (RCA-ALSS therapy). This study aimed to develop a predictive scoring system to stratify the risk of citrate accumulation. A total of 338 patients treated with RCA-ALSS therapy were retrospectively enrolled and randomly divided into derivation and validation cohorts. Longer duration of citrate accumulation (LDCA) was defined as the presence of citrate accumulation 2 h after RCA-ALSS therapy. Four baseline variables were found to be independently associated with LDCA: gender, international normalized ratio of prothrombin time, serum creatinine, and serum chloride. A predictive R-CA model and its simplified R-CA score were developed. The R-CA model (AUROC = 0.848) was found to be superior to the MELD score (AUROC = 0.725; p = 0.022) and other univariate predictors (AUROCs < 0.700; all p ≤ 0.001) in predicting LDCA. The R-CA score (AUROC = 0.803) was as capable as the R-CA model (p = 0.369) and the MELD score (p = 0.174), and was superior to other univariate predictors (all p < 0.05) in predicting LDCA. An R-CA score of 0–2 had a negative predictive value of 90.2% for LDCA. Our R-CA score reliably predicts LDCA in patients with RCA-ALSS therapy, and it is easy to use. Patients with R-CA score of 0–2 can safely receive RCA-ALSS therapy, while others should be carefully evaluated before treatment.Trial registration: Chinese Clinical Trial Registry, ChiCTR2000029179. Registered 17 January 2020, https://www.chictr.org.cn/showproj.aspx?proj=48084.
Highlights
Patients with liver failure may suffer citrate accumulation when using regional citrate anticoagulation for artificial liver support system therapy (RCA-Artificial liver support system (ALSS) therapy)
Schultheiß et al found that standard laboratory liver function parameters showed poor predictive capabilities regarding citrate accumulation and that serum lactate ≥ 3.4 mmol/L and prothrombin time activity (PTA) ≤ 26% predicted an increase of citrate accumulation with high sensitivity (86% for both lactate and PTA) and specificity (86% for lactate, 92% for PTA)[8]
The results were obtained in critically ill patients with decompensated liver cirrhosis or acute liver failure treated with continuous venovenous hemodialysis (CVVHD), though they may be useful for patients with Acute-on-chronic liver failure (ACLF) treated with ALSS therapy that includes dialysis and filtration techniques
Summary
Patients with liver failure may suffer citrate accumulation when using regional citrate anticoagulation for artificial liver support system therapy (RCA-ALSS therapy). An increase of citrate accumulation due to PE therapy was predicted by the presence of baseline levels of plasma lactate ≥ 2.65 mmol/L [sensitivity 62.5%, specificity 84.2%, area under the receiver operating curves (AUROCs) = 0.750, 95% confidence interval (CI) = 0.601–0.899]16. Whether these results could be applied to patients with ACLF who receive ALSS therapy without dialysis and filtration techniques is unclear. We developed a model to predict longer duration of citrate accumulation (LDCA) in patients with hepatitis B virus (HBV) infectionrelated liver injury treated with DPMAS plus PE therapy with RCA
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