Abstract
Citrate has been proposed as anticoagulation of choice in continuous renal replacement therapy (CRRT). However, little is known about the pharmacokinetics (PK) and metabolism of citrate in liver failure patients who require CRRT with regional citrate anticoagulation (RCA). This prospective clinical PK study was conducted at King Chulalongkorn Memorial Hospital between July 2019 to April 2021, evaluating seven acute liver failure (ALF) and seven acute-on-chronic liver failure (ACLF) patients who received CRRT support utilizing RCA as an anticoagulant at a citrate dose of 3 mmol/L. For evaluation of the citrate PK, we delivered citrate for 120 min and then stopped for a further 120 min. Total body clearance of citrate was 152.5 ± 50.9 and 195.6 ± 174.3 mL/min in ALF and ACLF, respectively. The ionized calcium, ionized magnesium, and pH slightly decreased after starting citrate infusion and gradually increased to baseline after stopping citrate infusion. Two of the ACLF patients displayed citrate toxicity during citrate infusion, while, no ALF patient had citrate toxicity. In summary, citrate clearance was significantly decreased in critically ill ALF and ACLF patients receiving CRRT. Citrate use as an anticoagulation in these patients is of concern for the risk of citrate toxicity.
Highlights
Citrate has been proposed as anticoagulation of choice in continuous renal replacement therapy (CRRT)
The mean APACHE II and SOFA scores were lower in the acute liver failure (ALF) group (19.6 ± 4.1 and 13.7 ± 3.7, respectively), than in the acute-on-chronic liver failure (ACLF) group (24.0 ± 5.6 and 15.6 ± 3.5, respectively)
Most laboratory values were comparable between the two groups, except for the direct bilirubin values, which were higher in the ALF group than in the ACLF group (11.3 [9.8,14.5] vs. 6.2 [3.6,11.2] mg/dL)
Summary
Citrate has been proposed as anticoagulation of choice in continuous renal replacement therapy (CRRT). Little is known about the pharmacokinetics (PK) and metabolism of citrate in liver failure patients who require CRRT with regional citrate anticoagulation (RCA). Citrate clearance was significantly decreased in critically ill ALF and ACLF patients receiving CRRT. Regional citrate anticoagulation (RCA) is the first-line anticoagulation in critically ill patients receiving continuous renal replacement therapy (CRRT)[1]. To the best of our knowledge, no study has been conducted to demonstrate the citrate PK in critically ill ALF or ACLF patients receiving CRRT. To address this knowledge gap of RCA in CRRT, we first evaluated the citrate PK and metabolism among critically ill acute decompensated liver failure patients receiving CRRT
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