COMPARISON OF DILUTED VS CONCENTRATED REGIONAL CITRATE ANTICOAGULATION IN CRRT - INDIAN SENARIO

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COMPARISON OF DILUTED VS CONCENTRATED REGIONAL CITRATE ANTICOAGULATION IN CRRT - INDIAN SENARIO

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Co-author 1

MAHESH KOTA mahesh9700502390@gmail.com YASHODA HOSPITAL NEPHROLOGY HYDERABAD India *

Co-author 2

RAJASEKARA CHAKRAVARTHI rajasekarac@gmail.com YASHODA HOSPITAL NEPHROLOGY HYDERABAD India -

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Introduction

Starting a CRRT in India is never early, it definitely takes a long time to in India to convince a patient to undergo CRRT(continuous renal replacement therapy) due to financial reasons and other social reasons.By the time we start CRRT in India most of the patients are in severe shock/metabolic acidosis requiring multiple vasopressors ,in this clinical scenario these patients require good anticoagulant to keep the circuit patent and treating physician should be aware of all the pros and cons of using anticoagulant drugs.As regional citrate anticoagulation (RCA) is still in development in Indian scenario we compared diluted vs concentrate citrate anticoagulant in Indian patient population.

Methods

This prospective experimental study was carried out in the intensive care unit of a quarternary care hospital (in Hyderabad,India). Consecutive adult patients requiring continuous renal replacement therapy with citrate were included. The sample was divided into two groups, a concentrated citrate group and a diluted citrate group. The decision to initiate anticoagulation with diluted (18 mmol/L) or concentrated (136 mmol/L) citrate was made based on the machine available and the decision of the doctor responsible for the patient. It was not possible to randomize the sample. Both protocols were matched based on targeted post filter ionised calcium of less than 0.3 mM and a dialysis solution with out calcium was used. Isotonic bicarbonate was used as post-filter replacement fluid based on patient acid-base status and the citrate solution was the only fluid administered pre-filter.As commercially made calcium chloride solution for concentrate citrate protocol is not available in India, we used diluted calcium gluconate( 500ml of 10% calcium gluconate was mixed with 500ml 5% Dextrose) as calcium replenishment fluid which is given calcium infusion pump in CRRT machine to keep systemic ionised calcium between 0.9mM to 1.2mM.

Results

The analysis included 12 circuits in the concentrated citrate group and 30 circuits in the diluted citrate group.After observation we found that filter life span and citrate toxicity was similar in both groups, membrane clogging and electrolytes replacement was more in diluted citrate group than concentrate citrate group, better solute clearance/metabolic alkalosis /risk of hypernatremia was more in concentrate citrate group than diluted citrate group.Nursing workload is more in concentrate citrate protocol than diluted citrate protocol.Statistically significant results was drawn because of less number of patients in each group.

Conclusion

As the primary target is to increase the filter life span and decrease metabolic complications related to RCA ,with better understanding of RCA protocols and fluids used for RCA both dilute and concentrate RCA protocols can be safely practiced in India.However as all commercial fluids required for the use of concentrate RCA is still not available in India,there is more nursing/dialysis technicians workload in preparing bedside custom made solutions for concentrate citrate protocol which might be decreased in future with availability of all commercially available fluids.

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