A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges

Sébastien Kissling (1) , Cécile Legallais (1) , Menno Pruijm (2) , Daniel Teta (2) , Bruno Vogt (2) , Michel Burnier (2) , Eric Rondeau (3) , Christophe Ridel (3)

1 BMBI - Biomécanique et Bioingénierie
2 CHUV - Centre Hospitalier Universitaire Vaudois = Lausanne University Hospital [Lausanne]
3 CHU Tenon [AP-HP]

Background: Regional citrate anticoagulation (RCA) is proposed for various extracorporeal purification techniquesto overcome the risk of bleeding that might result from systemic anticoagulation. Yet, no individualized treatmentprotocol has been proposed for therapeutic plasma exchange (TPE) so far. The objective of this study was to assessthe determinants of blood citrate concentration needed and to develop an individualized RCA protocol useful forclinical practice. Methods: The study population included 14 patients who underwent a total of 47 TPE sessions. Citrate wasinfused pre-plasmafilter. Post-plasmafilter and systemic plasma ionized calcium concentrations were measuredat standardized time intervals. An algorithm was proposed for the supplementation of calcium. During thediscovery phase, citrate was infused at a fixed starting rate, and adapted accordingly to obtained post-plasmafilterionized calcium levels. Using a mathematical approach, an algorithm was thereafter developed for individualizedprescriptions of citrate. Results: Pre-treatment values of hematocrit and plasma ionized calcium were the main determinants of the requiredrate of citrate infusion. These can be integrated into a final equation enabling to individualize the prescription. Aprefilter ionized calcium concentration between 0.24 and 0.33 mmol/l prevented coagulation of the extracorporealcircuit. Significant hypocalcemia occurred in 8.5% of treatments. There were no significant acid–base disturbances. Conclusion: We propose a new protocol, which enables for the first time to individualize the prescription of regionalcitrate anticoagulation during TPE, in an efficient manner. The immediately obtained regional anticoagulation protectsagainst both the risk of coagulation of the membrane and the exposure to an excess of citrate

Mots clés: Citrate; Clinical protocol; Drug prescription; Mathematical model; Plasma exchanges

Domaines: Urologie et Néphrologie; Ingénierie biomédicale

Sébastien Kissling, Cécile Legallais, Menno Pruijm, Daniel Teta, Bruno Vogt, et al.. A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges. BMC Nephrology, 2017, 18 (1), pp.81. ⟨10.1186/s12882-017-0494-9⟩. ⟨hal-02938371⟩