Abstract
Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75–14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29–74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.
Highlights
Pediatric acute and acute-on-chronic liver failure can lead to multiple organ failure and associated acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) [1]
We studied the population of pediatric patients receiving CRRT with concomitant acute and acute-on-chronic liver failure to establish safety and efficacy of Regional anticoagulation with citrate (RCA) in pediatric liver failure
Patients were identified from an institutional CRRT database based on International Classification of Diseases (ICD) 9 and 10 codes referring to acute and acute on chronic liver failure by one investigator (KR) and confirmed by chart review
Summary
Pediatric acute and acute-on-chronic liver failure can lead to multiple organ failure and associated acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) [1]. Underlying bleeding diatheses resulting from the primary disease process complicates anticoagulation in liver failure patients especially when extracorporeal therapies are used, with serious bleeding complications reported in 16–25% of patients [4,5]. [6] Regional anticoagulation with citrate (RCA) is the standard of care in our institution for all pediatric patients on CRRT. The report from pediatric prospective CRRT included 230 circuits with heparin anticoagulation and 158 circuits with citrate anticoagulation; 9 episodes of bleeding were observed with heparin based anticoagulation; no mention is made regarding bleeding episodes with citrate anticoagulation [7]. In the setting of liver failure, metabolism of citrate is impaired and accumulation can lead to a citrate toxicity-often known as “citrate lock” -where there is continued chelation of serum ionized calcium [17]. There currently is no consensus definition for CA validated in pediatric patients, which makes recognition and management by physicians challenging [19]
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