A novel citrate anticoagulation regimen for continuous venovenous hemodiafiltration

Objective. Validation of a novel citrate anticoagulation regimen for continuous venovenous hemodiafiltration (CVVHDF). Design and setting. Prospective cohort trial in medicosurgical intensive care units of two university-affiliated teaching institutions. Patients. Participants were patients at high risk for bleeding, with renal failure requiring CVVHDF without heparin. Fourteen patients completed the study. Intervention. A convection-based citrate anticoagulation CVVHDF regimen using an isotonic replacement fluid containing citrate administered in predilution. A neutralizing solution of calcium chloride and magnesium sulfate was infused at the end of the circuit. Blood flow rate was set and kept at 125 ml/min, and the flow rate of the replacement fluid was initiated at 1250 ml/h and adjusted thereafter according to the monitoring of blood activated coagulation time (ACT), with a target between 180 to 220 s. Measurements and results. The average filter time-life was 44 h. Thrombosis of the proximal portion of the circuit (which was not anticoagulated) was the main reason for technique failure. A mean urea clearance of 21 ml/min was obtained. Electrolytes and acid-base balance were both well maintained. Six percent (16/287) of Ca-i readings less than 0.3 mmol/l were associated with very high ACT levels (>300 s). Conclusions. This regimen is shown to be safe, efficacious, and convenient. Citrate anticoagulation should be monitored using postfilter ACT and/or ionized calcium with respective targets of 200-250 s or 0.3-0.4 mmol/l.