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      Complications of regional citrate anticoagulation: accumulation or overload?

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          Abstract

          Regional citrate anticoagulation (RCA) is now recommended over systemic heparin for continuous renal replacement therapy in patients without contraindications. Its use is likely to increase throughout the world. However, in the absence of citrate blood level monitoring, the diagnosis of citrate accumulation, the most feared complication of RCA, remains relatively complex. It is therefore commonly mistaken with other conditions. This review aims at providing clarifications on RCA-associated acid-base disturbances and their management at the bedside. In particular, the authors wish to propose a clear distinction between citrate accumulation and net citrate overload.

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          Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators.

          Little information is available regarding current practice in continuous renal replacement therapy (CRRT) for the treatment of acute renal failure (ARF) and the possible clinical effect of practice variation. Prospective observational study. A total of 54 intensive care units (ICUs) in 23 countries. A cohort of 1006 ICU patients treated with CRRT for ARF. Collection of demographic, clinical and outcome data. All patients except one were treated with venovenous circuits, most commonly as venovenous hemofiltration (52.8%). Approximately one-third received CRRT without anticoagulation (33.1%). Among patients who received anticoagulation, unfractionated heparin (UFH) was the most common choice (42.9%), followed by sodium citrate (9.9%), nafamostat mesilate (6.1%), and low-molecular-weight heparin (LMWH; 4.4%). Hypotension related to CRRT occurred in 19% of patients and arrhythmias in 4.3%. Bleeding complications occurred in 3.3% of patients. Treatment with LMWH was associated with a higher incidence of bleeding complications (11.4%) compared to UFH (2.3%, p = 0.0083) and citrate (2.0%, p = 0.029). The median dose of CRRT was 20.4 ml/kg/h. Only 11.7% of patients received a dose of > 35 ml/kg/h. Most (85.5%) survivors recovered to dialysis independence at hospital discharge. Hospital mortality was 63.8%. Multivariable analysis showed that no CRRT-related variables (mode, filter material, drug for anticoagulation, and prescribed dose) predicted hospital mortality. This study supports the notion that, worldwide, CRRT practice is quite variable and not aligned with best evidence.
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            Regional citrate anticoagulation for continuous arteriovenous hemodialysis in critically ill patients.

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              Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated meta-analysis of RCTs.

              The purpose of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy (CRRT) in critically ill patients by performing a meta-analysis of updated evidence.
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                Author and article information

                Contributors
                +41 21 314 16 32 , antoine.schneider@chuv.ch
                didier.journois@parisdescartes.fr
                thomas.rimmele@chu-lyon.fr
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                19 November 2017
                19 November 2017
                2017
                : 21
                : 281
                Affiliations
                [1 ]ISNI 0000 0001 0423 4662, GRID grid.8515.9, Adult Intensive Care Unit, , Centre Hospitalier Universitaire Vaudois (CHUV), ; 46 avenue du Bugnon, 1011 Lausanne, Switzerland
                [2 ]ISNI 0000 0001 2165 4204, GRID grid.9851.5, Université de Lausanne, UNIL, ; Lausanne, Switzerland
                [3 ]ISNI 0000 0001 2188 0914, GRID grid.10992.33, Anesthesiology and Intensive Care Medicine, Cochin Hospital, Assistance Publique Hôpitaux de Paris, , René Descartes University, ; Paris, France
                [4 ]ISNI 0000 0001 2198 4166, GRID grid.412180.e, Anesthesiology and Intensive Care Medicine, , Edouard Herriot Hospital, Hospices Civils de Lyon, ; Lyon, France
                [5 ]ISNI 0000 0001 2198 4166, GRID grid.412180.e, EA 7426 (Université Claude Bernard Lyon 1 – Hospices Civils de Lyon – bioMérieux) “Pathophysiology of Injury-induced Immunosupression – PI3”, Joint Research Unit, Edouard Herriot Hospital, ; Lyon, France
                Article
                1880
                10.1186/s13054-017-1880-1
                5694623
                29151020
                7f70649c-f30e-4464-827f-29a204fce0ea
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 31 July 2017
                : 31 October 2017
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                © The Author(s) 2017

                Emergency medicine & Trauma
                regional citrate anticoagulation,continuous renal replacement therapy,acute kidney injury,citrate accumulation,complications of therapy,metabolic alkalosis

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