1. Regional citrate anticoagulation for post-dilution hemofiltration provides long hemofiltration circuit lifespan in cardiac surgical patients
PM /2017
Original ESCIM Abstract information:A ref 040
Poster 3 - Acute renal failure and metabolism Session Date: 06 April 2017 Session Time: 18:42-18:49 Session Room: Exhibition Area
Slides reproduced with permissions for use during lectures and educational presentations, internal use within Nikkiso
Reproduced with the kind permission of Professor Romuald Lango and co authors.
Department of Cardiac Anaesthesia, Medical University of Gdańsk, Poland
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential
A ref 040

2. Introduction
Acute kidney injury requiring renal replacement therapy is a common complication in cardiac surgical patients.
Regional circuit anticoagulation with citrate provides ideal solution for these patients, as it does not influence the optimal antithrombotic prophylaxis adjusted to patients clinical condition and risk factors.
1). Kirwan C et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif 2016;42:349-55
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

3. Introduction
Newly developed regional citrate anticoagulation protocol for hemofiltration was introduced in September 2015, but the data on its effectiveness and influence on acid-base and ion balance in the literature are scanty.1
1). Kirwan C et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif 2016;42:349-55
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

4. Uniwersyteckie Centrum Kliniczne, Gdansk
Cardiothoracic Intensive Care Unit
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

5. First RCA Treatments2
2 Article at accessed , reproduced with the kind permission of the author.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

6. Developing shared tools3,4
3 Original publication from
and Polish translation in partnership with Uniwersyteckie Centrum Kliniczne and Nikkiso Poland.
4 Original Chart from PM – 0062_PL “RCA Prescription and Observation Template”, translated in partnership with Lublin ICU and Nikkiso Poland.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

7. Aquarius RCA to laptop link
Data collection
Aquarius RCA to laptop link
Speaker notes: raw anonymised data taken from Aquarius Data ports to Aqualog, interpreted using Termite freeware and Excel. Blood samplingdata allocated via the ICU blood gas machine.
Data from here To here
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

8. Objectives
Assessment of hemofiltration circuit lifespan during post-dilution hemofiltration with regional citrate anticoagulation in cardiac surgical patients.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

9. Methods
Retrospective analysis of all patients treated with post-dilution hemofiltration with regional citrate anticoagulation during the first 16 months after introduction of new citrate anticoagulation protocol for Aquarius System.
Following data were collected: systemic anti-thrombotic, anti-platelet therapy, duration of hemofiltration session, reason for ending hemofiltration session, complications and technical problems leading to termination of hemofiltration.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

10. Methods Data are presented as median value, quartiles, and ranges.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

11. Results
107 hemofiltration treatment sessions in the first 30 patients treated with post-dilution hemofiltration
with regional citrate anticoagulation in
the department.
13 sessions were finished due to reasons
other than filter clotting or planned termination
of treatment.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

12. Results
Median duration of hemofiltration treatment session was 60 hours (Q1=29, Q3=80, Range: 2-117)
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

13. Results Following antithrombotic prophylaxis was used
unfractionated heparin (UFH) infusion alone – 2 (2.1 %)
UFH with acetyl-salicylic acid (ASA) 150 mg – 2 (2.1 %)
ASA only – 4 (4.3 %)
fondaparinux PD 19 (20.2 %)
fondaparinux therapeutic dose – 1 (1.1 %)
no antithrombotic prophylaxis and no ASA 26 (27.7 %)
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

14. Results Following antithrombotic prophylaxis was used
LMWH prophylactic dose (PD) alone – 18 (19.1 %)
LMWH PD with ASA – 5 (5.3 %)
LMWH > PD alone – 8 (8.5 %)
LMWH > PD with ASA – 9 (9.6 %)
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

15. Results
The following reasons for hemofiltration termination were reported
planned/set expired – 40 (42.6 %)
filter clotting – 5 (5.3 %)
air trap clotting – 4 (4.2 %)
clotting non-defined – 14 (14.9 %)
catheter-related – 1 (1 %)
not recorded – 27 (28.7 %)
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

16. Conclusions
New regional citrate anticoagulation protocol for hemofiltration provides long circuit survival in most of cardiac surgical patients, who receive their routine surgical antithrombotic prophylaxis according to local protocol.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

17. Any Questions?
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

18. References
1 Kirwan C et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif 2016;42:349-55
2 Shannon, S The Pioneers of Poland. Critical Care Scientist. Vol 15, Series 6, Autumn accessed , reproduced with the kind permission of the author.
3 Prowle J et al. Protocol for Regional Citrate! Anticoagulation on the Aquarius CRRT Platform at the Royal London Hospital. V1.7. DOI: /RG Accessed Translation in partnership with Uniwersyteckie Centrum Kliniczne, Gdansk and Nikkiso Poland, reproduced with the kind permission of the author.
4 PM_ 0062_PL RCA Prescription and Observation Template. Translation in partnership with Lublin ICU and Nikkiso Poland.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

19. Regional citrate anticoagulation for post-dilution hemofiltration provides low risk of citrate accumulation and reasonable pH homeostasis in cardiac surgical patients
Original ESCIM Abstract information: A ; ref 036
Poster 3 - Acute renal failure and metabolism Session Date: 06 April 2017 Session Time: 18:14-18:21 Session Room: Exhibition Area
Slides reproduced with permissions for use during lectures and educational presentations, internal use within Nikkiso
Reproduced with the kind permission of Dr Agnieszka Kośka and co authors. Department of Cardiac Anaesthesia, Medical University of Gdańsk, Poland
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential
A  Ref 036

20. Introduction
With higher blood flows, in comparison to hemodialysis, citrate anticoagulation of hemofiltration circuit is related to increased citrate burden and risk of its accumulation.
Acid-base derangement resulting from regional citrate anticoagulation of extracorporeal circuit may take a form of metabolic alkalosis and high anion-gap metabolic acidosis.
Citrate toxicity is likely when total to ionized calcium concentration ratio exceeds 2.5.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

21. Objectives
To assess acid-base homeostasis and citrate accumulation, by total to ionized calcium ratio during post-dilution hemofiltration with new regional citrate anticoagulation protocol.1
1). Kirwan C et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif 2016;42:349-55
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

22. Methods
A retrospective analysis of 30 patients treated with post-dilution hemofiltration with regional citrate anticoagulation protocol for Aquarius System with Regional Citrate Anticoagulation in the postoperative cardiac surgery department.
Specified data collected before starting hemofiltration and every 24 hours during the treatment: pH, HCO3, anion gap, and ionized and total calcium concentration in serum.
Median value, ranges, as well as lower and upper quartiles were used as descriptive statistics.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

23. Results
107 hemofiltration treatment sessions with regional citrate anticoagulation.
3 sessions were excluded due to patient death before 24 hours of hemofiltration treatment and 2 due to missing data, leaving 102 in the analysis.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

24. Results
Total to ionized calcium ratio exceeding 2.5 was observed in 2 sessions before start of hemofiltration session, in 3 sessions after 24 hours and in 1 session after 48 hours of hemofiltration treatment (altogether in 6 time-points of all sessions) including one exceeding 4.
HCO3- concentration, pH, anion gap and total to ionized calcium concentration ratio are presented in the table.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

25. Results Parameter pH HCO3- Anion gap Total/Ionized Calcium 7.37 7.39
Before HF (N=102)
After 24 h. (N=87)
After 48 h. (N=66)
After 72 h. (N=39) pH
7.37
( )
Q1=7.3,Q3=7.41
7.39
( )
Q1=7.35,Q3=7.44
( )
Q1=7.35,Q3=7.45
( )
HCO3-
24.9
(8.4-53)
Q1=21.4,Q3=27.6
27.3
( )
Q1=25.5,Q3=29.1
27.4
( )
Q1=25.6,Q3=29.6
( )
Q1=25,Q3=29.5
Anion gap
12.5
( )
Q1=9.5,Q3=15.1
10.7
(0-23.7)
Q1=8.4,Q3=12.7
9.5
( )
Q1=7.3,Q3=12.8
Total/Ionized
Calcium
2.02
( ) Q1=1.84,Q3=2.14
2.08
( ) Q1=1.94,Q3=2.22
2.04
( ) Q1=1.9,Q3=2.28
2.16
( ) Q1=2.06,Q3=2.3
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

26. Conclusions
New citrate anticoagulation protocol for hemofiltration with Nikkiso Aquarius platform provides:
Reasonable acid-base homeostasis.
Low risk of citrate toxicity in cardiac surgical patients with acute renal failure.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

27. Forthcoming Publication
A manuscript submission to Blood Purification by the Gdansk team is intended.
Thank you for your attention.
This overview was granted with kind permission by the abstract authors for educational purposes
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

28. Any Questions?
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

29. References
1 Kirwan, C et al. Implementation of a simplified regional citrate anticoagulation protocol for post-dilution continuous hemofiltration using a bicarbonate buffered, calcium containing replacement solution. Blood Purif 2016;42:349-55
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential

30. AQUARIUS system
NIKKISO Europe GmbH
Desbrocksriede 1
30855 Langenhagen
Germany
ACCUSOL solution*
Nikkiso Belgium bvba
Industriepark 6
3300 Tienen
Belgium
* Registered as a drug and/or a medical device
AQUAMAX hemofilter
Nikkiso Belgium bvba
Industriepark 6
3300 Tienen
Belgium
AQUALINE tubing
Haemotronic S.p.A.
Via Carreri, 16
41037 Mirandola
Italy
AQUASET and CITRASETRCA
Haemotronic S.p.A.
Via Carreri, 16
41037 Mirandola
Italy
AquariusTM, AccusolTM, AquamaxTM and AquasetTM are trademarks of Nikkiso Co., Ltd.
Copyright © 2017 NIKKISO Co., LTD. All rights reserved. | Confidential