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Previous Volume 338:131-132 January 8, 1998 Number 2 Next

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To the Editor: Hsu et al. (Sept. 4 issue)¹ describe a method of regional anticoagulation for continuous venovenous hemofiltration that involves the infusion of a citrate-containing replacement fluid. For over a year we have used a similar technique, in which a replacement fluid containing 15 mmol of disodium citrate per liter is infused at a fixed rate of 2 liters per hour, volume control is achieved by variable ultrafiltration, and the blood-flow rate is set at 60 to 150 ml per minute. This approach achieves metabolic control equivalent to that with lactate-based solutions. Correction of acidosis, however, can be insufficient in cases of severe shock because low hepatic perfusion may compromise the conversion of citrate into bicarbonate. In patients with acidosis due to impaired organ perfusion, we use a solution containing both citrate and bicarbonate (15 mmol of disodium citrate per liter and 10 mmol of sodium bicarbonate per liter).

In addition to reducing the risk of hemorrhage, anticoagulation with citrate for continuous hemofiltration may also offer other advantages. Hypercoagulability may be a new indication for citrate anticoagulation. We achieved a nearly normal filter life by using citrate in patients in whom the extracorporeal system usually clots in less than six hours (despite excessive heparinization) because of high fibrinogen levels and elevated platelet counts. The side effects associated with heparin, such as thrombocytopenia, thrombosis, increased vascular permeability, and hyperlipidemia,² can be avoided with the use of citrate. In addition, patients with the systemic inflammatory response syndrome might benefit from the inhibition of calcium-mediated activation of inflammatory cells in the extracorporeal circulation.³ For these reasons we are convinced that regional anticoagulation with citrate, performed with modern volume-controlled hemofiltration devices, will replace conventional anticoagulation with heparin within the next decade.

Robert Apsner, M.D.
Wilfred Druml, M.D.
University of Vienna
A-1090 Vienna, Austria

References

1. Hsu C-Y, Palsson R, Niles JL. Continuous hemofiltration. N EnglJ Med 1997;337:713. 
2. Hirsh J, Raschke R, Warkentin TE, Dalen JE, Deykin D, Poller L. Heparin: mechanism of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest 1995;108:Suppl:258S-275S. [Free Full Text]
3. Böhler J, Schollmeyer P, Dressel B, Dobos G, Hörl WH. Reduction of granulocyte activation during hemodialysis with regional citrate anticoagulation: dissociation of complement activation and neutropenia from neutrophil degranulation. J Am Soc Nephrol 1996;7:234-241. [Abstract]

To the Editor: We agree with Apsner and Druml that citrate should replace heparin as the anticoagulant in the majority of patients requiring continuous venovenous hemofiltration. Two factors currently limiting the widespread adoption of this approach are the lack of standardized protocols and the lack of commercially available citrate-containing replacement fluids. However, we would like to reiterate that this system is not suitable for the minority of patients who cannot adequately metabolize citrate, a condition that can cause hypocalcemia and exacerbate acidosis.

The first sentence of the second paragraph of our original letter should have read, "In brief, we infuse an isotonic sodium citrate–based replacement fluid proximal to the hemofilter."

Chi-yuan Hsu, M.D.
Massachusetts General Hospital
Boston, MA 02114

Runolfur Palsson, M.D.
Reykjavik City Hospital
Reykjavik, Iceland

John L. Niles, M.D.
Massachusetts General Hospital
Boston, MA 02114

Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited Related Article Related Article by Hostetter, T. H. PubMed Citation

Related Letters:

Continuous Hemofiltration
Hostetter T. H., Manske C. L., Paller M. S., Hsu C.-y., Palsson R., Niles J. L., van Bommel E. F.H., Grootendorst A. F., Forni L.G., Hilton P.J.
Extract | Full Text  
N Engl J Med 1997; 337:712-714, Sep 4, 1997. Correspondence

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