Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

Rationale: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus r...

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Autores principales:	Thiago Reis, Geraldo Rubens Ramos de Freitas, Fábio Reis, Maria Letícia Cascelli de Azevedo, Priscila Dias, Diêgo Fernando Figueiredo Santos, Rodrigo Alfredo Vivanco Vergara, Luca Sgarabotto, Evandro Reis da Silva Filho, Claudio Ronco
Formato:	article
Lenguaje:	EN
Publicado:	SAGE Publishing 2021
Materias:	Diseases of the genitourinary system. Urology RC870-923
Acceso en línea:	https://doaj.org/article/572ca0bba22244f4ab0c3287244cd3aa
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spelling	oai:doaj.org-article:572ca0bba22244f4ab0c3287244cd3aa2021-11-08T23:03:31ZRegional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series2054-358110.1177/20543581211054736https://doaj.org/article/572ca0bba22244f4ab0c3287244cd3aa2021-11-01T00:00:00Zhttps://doi.org/10.1177/20543581211054736https://doaj.org/toc/2054-3581Rationale: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events. Presenting concerns of the patient: (1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm 3 even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided. Diagnoses: (1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement. Interventions: Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation. Outcomes: All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter. Teaching points: In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.Thiago ReisGeraldo Rubens Ramos de FreitasFábio ReisMaria Letícia Cascelli de AzevedoPriscila DiasDiêgo Fernando Figueiredo SantosRodrigo Alfredo Vivanco VergaraLuca SgarabottoEvandro Reis da Silva FilhoClaudio RoncoSAGE PublishingarticleDiseases of the genitourinary system. UrologyRC870-923ENCanadian Journal of Kidney Health and Disease, Vol 8 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	Diseases of the genitourinary system. Urology RC870-923
spellingShingle	Diseases of the genitourinary system. Urology RC870-923 Thiago Reis Geraldo Rubens Ramos de Freitas Fábio Reis Maria Letícia Cascelli de Azevedo Priscila Dias Diêgo Fernando Figueiredo Santos Rodrigo Alfredo Vivanco Vergara Luca Sgarabotto Evandro Reis da Silva Filho Claudio Ronco Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
description	Rationale: Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events. Presenting concerns of the patient: (1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm 3 even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided. Diagnoses: (1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement. Interventions: Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation. Outcomes: All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter. Teaching points: In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.
format	article
author	Thiago Reis Geraldo Rubens Ramos de Freitas Fábio Reis Maria Letícia Cascelli de Azevedo Priscila Dias Diêgo Fernando Figueiredo Santos Rodrigo Alfredo Vivanco Vergara Luca Sgarabotto Evandro Reis da Silva Filho Claudio Ronco
author_facet	Thiago Reis Geraldo Rubens Ramos de Freitas Fábio Reis Maria Letícia Cascelli de Azevedo Priscila Dias Diêgo Fernando Figueiredo Santos Rodrigo Alfredo Vivanco Vergara Luca Sgarabotto Evandro Reis da Silva Filho Claudio Ronco
author_sort	Thiago Reis
title	Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_short	Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_full	Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_fullStr	Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_full_unstemmed	Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series
title_sort	regional hypertonic citrate anticoagulation in membrane therapeutic plasma exchange: a case series
publisher	SAGE Publishing
publishDate	2021
url	https://doaj.org/article/572ca0bba22244f4ab0c3287244cd3aa
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Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

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