Dataset Information

Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment.

ABSTRACT:

Background and objectives

A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.

Design, setting, participants, & measurements

All patients treated with SLED (8- to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.

Results

This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (< 3.6 mg/dl or < 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).

Conclusions

This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.

SUBMITTER: Fiaccadori E

PROVIDER: S-EPMC3789332 | biostudies-literature | 2013 Oct

REPOSITORIES: biostudies-literature

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Publications

Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment.

Fiaccadori Enrico E Regolisti Giuseppe G Cademartiri Carola C Cabassi Aderville A Picetti Edoardo E Barbagallo Maria M Gherli Tiziano T Castellano Giuseppe G Morabito Santo S Maggiore Umberto U

Clinical journal of the American Society of Nephrology : CJASN 20130829 10

<h4>Background and objectives</h4>A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.<h4>Design, setting, participants, & measurements</h4>All patients treated with SLED (8- to 12-hour sessions) for AKI in four intensive care uni ...[more]

PMID: 23990164

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Project description:IntroductionInitiating dialysis in acute kidney injury (AKI) in an intensive care unit (ICU) remains a subjective clinical decision. We examined factors and practice patterns that influence early initiation of dialysis in ICU patients with acute kidney injury.MethodsAn online survey presented nephrologists (international) with three case scenarios with unstated predicted mortality rates of < 10%, 10 - 30% and > 30%. For each case the respondents were asked 4 questions about influences on the decision whether or not to initiate dialysis within 24 hours: Q1, likelihood of initiating dialysis; Q2, threshold of BUN levels (< 50, 50 - 75, 76 - 100, > 100 mg/dl) considered relevant to this decision; Q3, magnitude of creatinine elevation (two to three-fold increase; greater than threefold increase; absolute level > 5 mg/dl regardless of change) considered relevant; Q4, a rank order of the influence of five parameters (BUN level, change of creatinine from baseline, oxygen saturation, potassium level, and urine output), 1 being the most influential and 5 being the least influential.ResultsOne hundred seventy-two nephrologists (73% in practice for > 5 years; 70% from the U.S.A.) responded to the survey. The proportion of subjects likely to initiate early dialysis increased (76% to 94%), as did the predicted mortality (p < 0.001). The proportion of subjects considering early dialysis at a BUN level ? 75 increased from 17% to 30 to 40% as the predicted mortality of the cases increased (p < 0.0001). The proportion of subjects choosing absolute creatinine level to be more influential than relative increment, went from 60% to 54% to 43% as predicted mortality increased (p < 0.0001). Rank-order analysis indicated that influence of oxygen saturation and potassium level on dialysis decision showed a significant change with severity of illness, but BUN level and creatinine elevation remained less influential, and did not change with severity.ConclusionsSeverely ill patients were more likely to be subjected to early dialysis initiation, but its utility is not clear. Rank-order analysis indicates dialysis initiation is still influenced by "imminent" indications rather than a "proactive" decision based on the severity of AKI or azotemia.

Dataset Information

Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment.

Background and objectives

Design, setting, participants, & measurements

Results

Conclusions

Publications

Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment.

Similar Datasets

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