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Welcome to Katie. 
Go conversations in Nephrology. 

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This episode is titled 
maximizing filter life. 

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During see our Arty. 
Best practices on any 

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coagulation and citrate use. 
Here's your host dr. 

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Ravi meta. 
How does one go about maximizing

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food to life during CRT today we
discuss best practices on 

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anticoagulation and citrate. 
Use, hello and welcome to KD. 

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Go conversation Nephrology, I'm 
dr. 

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Avi Mehta Professor of medicine 
at the University of California,

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San Diego, and on the program. 
With me today to discuss 

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maximizing filter life during 
CRT is dr. 

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Ashida to Ronnie in order to 
Ronnie is a professor of 

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medicine at the University of 
Alabama, in Birmingham, in the 

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United States, her research 
interests include acute. 

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Kidney injury, is you Nephrology
and CRT, and she's an expert on 

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sitted anticoagulation. 
So, certainly the perfect guest 

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for our topic today, dr. 
Tehrani. 

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Welcome to the program. 
It's an honor to be here. 

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Thank you so much for inviting 
me. 

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So she'd have to start. 
Why is the circuit patency and 

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integrity important for CRT and 
what are the key issues that we 

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should consider CR T stands for 
continuous, renewal placement 

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therapy. 
So to provide effective solute 

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clearance include removal and 
really needs to run 

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uninterrupted. 
And we know that decreased 

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circuit patency results. 
In significant time off the CRT 

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device, this has adverse 
consequences, such as decreased,

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Re of dose decrease, fluid 
removal goals, increased loss of

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blood, if you hit return the 
blood when the filter clots, it 

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also increases the burden for 
the nurses who need to keep 

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replacing the filter and 
increases costs, because extra 

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filters are used, you have 
wastage of CRT solutions to. 

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So making sure the circuit stays
Peyton's very important, and 

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there are several 
characteristics that you have to

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consider that affect circuit. 
Patency, I would say, probably 

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the most important is the 
vascular Access. 

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Vascular. 
Access dysfunction is a very 

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common cause of delayed circuit 
life so it's very important. 

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You have the correct catheter 
length for the correct position 

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and the tip should be the 
correct location. 

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The best catheters that work for
CRT are a right IJ catheter. 

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Other things that affect circuit
patency are really circuit 

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related factors, adding 
stopcocks to the system 

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increases resistance, you know, 
many of the CRT device. 

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Have a deaeration chamber and 
that are blood interface can 

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cause clotting, if you don't 
have a proper layering of fluid,

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nursing delays in addressing 
alarms. 

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Also can cause increased circuit
clotting because the blood pump 

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continues, while the other pumps
do not and that can contribute 

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to filter clotting, especially 
since the patient, won't be 

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getting an anticoagulant. 
The mode of therapy also affects

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circuit. 
Paint see what convective 

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therapy since you have high 
ultra, filtration rates in, 

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you're pulling plasma through 
the filter, you have increased. 

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Viscosity by the end of the 
filter with increased somatic. 

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Rip this can prone to clotting. 
We measure this effect by 

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something called, filtration, 
fraction. 

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Filtration fractions is the 
fraction of plasma, that is 

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removed from blood during 
hemofiltration, and it, ideally 

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should be kept less than 20 to 
25% to decrease the chance of 

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circuit. 
Clotting with convective 

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therapies. 
The way to do this, is by either

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using an increased blood flow, 
right? 

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Or by using more pre dilutional 
replacement fluid Only even if 

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you have optimized all these 
circuit characteristics, you 

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still have increased cloudy in 
the circuit because exposure to 

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an extra Corporal, circuit 
activates clotting Cascade. 

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So, insufficient anticoagulation
is a big deal. 

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Thank you for bringing out. 
These really important elements 

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for the circuit, given that 
anticoagulation techniques are 

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present and so variable. 
How do you decide which one to 

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use and is it really necessary 
to use anticoagulation? 

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There have been Been described 
in the literature. 

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No anticoagulation, protocols, 
having effective circuit 

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patency, and you can definitely 
maintain Circuit patency by 

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optimizing all those circuit 
factors. 

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We just talked about like the 
access, the circuit issues, ETC.

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But even if you have a circuit 
Peyton, that doesn't mean that 

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you're actually delivering the 
proper dose of therapy because 

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we know over time the filter 
permeability decreases. 

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And this decreases the diffusive
or convective loss of solute 

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through that filter essentially 
it Kris has your solute delivery

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or I should say dose given that 
I recommend that anticoagulation

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should be used for that purpose.
The most common anticoagulants 

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used for CRT or unfractionated 
Heparin and Regional citrate 

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anticoagulation other options. 
You may see in the literature 

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are unfractionated Heparin with 
protamine low, molecular weight 

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Heparin thrombin antagonist, 
pepper noise or platelet 

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inhibiting factors. 
We all are familiar with 

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unfractionated Heparin. 
It's Easy to use, has a short, 

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half-life we all know how to use
it, but we know there's 

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significant disadvantages to it 
has unpredictable 

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pharmacokinetics, so that 
results in a dosing variability,

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there's a risk of Heparin 
resistance due, to low 

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antithrombin levels, the 
development of potentially 

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heparin-induced 
thrombocytopenia. 

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But I think the biggest drawback
of systemic Heparin is that the 

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risk of hemorrhage, systemic 
Hemorrhage of the patient, and 

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We Know by multiple studies, 
that it really does increase 

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life-threatening hemorrhage. 
For these patients. 

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So that's why citrate has become
more common because it's a 

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regional anticoagulant. 
So basically the way citrate 

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works, it chelate, sinai's 
calcium. 

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And if you look at the clotting 
Cascade, free calcium is 

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required at every step. 
So, if you get the ionized 

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calcium, low enough in the 
circuit, the filter cannot clot.

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So the optimal level was an 
ionized calcium lesson point 4 

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millimoles per liter and that 
fact of the anticoagulant is 

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reversed by providing. 
In a calcium infusion back to 

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the patient and keeping the 
ionized calcium in normal 

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levels. 
So that's how citrate works and 

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why it's a little bit better 
than Heparin because it doesn't 

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have the systemic effects. 
Now, when you're really choosing

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an anticoagulant for the 
patient, it should be 

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individualized, it should be 
based on not only the patient's 

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condition but also the 
availability and expertise at 

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the institution. 
So in sensually, you really need

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to focus on safety of the 
patients. 

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So patients who cannot tolerate 
anticoagulation because they 

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have a high risk of bleeding. 
No, we should all sit right. 

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Anticoagulation. 
If you have the expertise would 

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be preferred in patients. 
Who have normal or moderately 

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Disturbed hemostasis. 
Then using Heparin would be 

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probably appropriate, impatience
of Heparin induced 

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thrombocytopenia. 
You may consider a gas turbine 

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or Bible route in, but no matter
which anticoagulant used you 

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would change it according to 
your patient's condition and 

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your expertise that was very 
helpful given that Regional 

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sat/rad anticoagulation is now 
Increasingly used, and is being 

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recommended as a preferred 
method for anticoagulation. 

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Is there adequate evidence to 
support this? 

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There is, there were multiple 
randomized trials. 

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Now, comparing Regional citrate 
anticoagulation to Heparin and 

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most some have suggested that 
citrate provides increased 

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filter. 
Patency, in fact, there was a 

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meta-analysis published several 
years ago of 11 randomized, 

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trials and nearly 1,000 patients
with show that the risk of 

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circuit loss was Or with RCA and
that she had decreased bleeding 

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and by the way this was recently
confirmed in a large Germans 

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multicenter study of 600 
patients and it's for these 

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reasons that que digo has 
recommended the use of citrate 

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is first line for patients with 
Aki reading CRT. 

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I know Ishita you have utilized 
arcia protocols for citrus 

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safely and effectively for many 
years. 

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What are the parameters that 
should be monitored? 

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Third, both for circuit 
integrity and how frequently 

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should these be done to assure 
the best performance? 

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Okay. 
Well, first of all, want to say 

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that RCA's available for all CRT
modalities and even if the 

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patient is systemically 
anticoagulated, you should still

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use our CA because you want 
complete control of the circuit,

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you don't know what's going to 
happen with the systemic 

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anticoagulation. 
When it's going to be stopped 

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excetera. 
So we use it, even in patients, 

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who are systemically 
anticoagulated. 

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When you give RCA, it could be 
delivered as a fixed ratio 

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between the blood and citrate, 
infusions, or titrated based on 

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ionized calcium levels. 
Many of the CRT machines these 

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days have our see a software 
that allows for safer and easier

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delivery of the RCA. 
But, unfortunately, it's not 

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available everywhere including 
the United States. 

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Given that truly important to 
know, all the different 

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components you have to think 
about When developing a citrate 

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protocol. 
The first component, of course, 

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is a citrate solution. 
Citrate Solutions can be 

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classified as either hypertonic.
They have a high level of sodium

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in their concentrated or 
basically physiological 

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solutions, that have a normal 
concentration of sodium. 

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The hypertonic Solutions are 
administered as a separate 

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citrate solution and is distinct
from the replacement or 

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dialysate Solutions. 
While the isotonic Solutions 

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with a physiological sodium 
content are dilute and are used 

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as an anticoagulant in a pre 
delusional. 

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Placement fluid depending on 
which CRT solution use, you have

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to choose what type of CRT other
solutions to use dependent on 

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the citrate choice. 
For instance, if you use some of

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the hypertonic Solutions, you 
may have to use hyponatremic 

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solutions for CRT like a 
replacement fluid or dialysate 

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or even a lower buffer 
concentration, since citrate is 

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converted to bicarbonate. 
The liver for using the isotonic

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dilute Solutions, you can use a 
commercially available 

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Solutions. 
Without any issue, the other 

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thing to be aware of is the 
potential complications of RCA 

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these include hypernatremia, 
depending on citrate solution to

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use a since sit regulates 
calcium, you can have hypo or 

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hypercalcemia citrate. 
Also calculates magnesium's you 

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had can have hypomagnesemia and 
of course since it rate is 

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converted to bicarbonate, liver 
is working. 

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There are acid base disorders, 
you have to be aware of most of 

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the time when you're monitoring 
for citrate most protocols 

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Archer blood, electrolytes, 
including the circuit and 

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systemic ionized calcium is at 
least every six hours or more 

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frequently. 
If there are changes made, or if

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there's concern for accumulation
of citrate, the bottom line is 

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that in order to have a proper 
RCA protocol, you need a 

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comprehensive algorithm of how 
to adjust the rates of the 

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different components to prevent 
or correct for any of the 

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acid-base abnormalities. 
And finally, one last thing I 

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just want to say, Is that 
patients with severe liver 

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failure or lactic acidosis? 
May have difficulty in 

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metabolizing citrate. 
So you need to be able to 

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recognize citrate accumulation 
and how to correct for it again.

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RCA's been used safely in 
patients with Advanced liver 

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disease and with lactic acidosis
and these metabolic 

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complications can be avoided if 
you use really strict, 

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protocols, appropriate training 
and of course safer, citrate 

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Solutions. 
Integrated citrate software to 

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have that availability. 
Thank you for sharing those. 

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For those just joining us. 
This is que digo conversation 

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Nephrology. 
I'm dr. 

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Ravi meta. 
And I'm speaking with dr. 

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Ashida to levani on maximizing 
filter life during CRT best 

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practices on anticoagulation and
citrate use so dr. 

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Shivani what have been the 
challenges you've seen during 

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the pandemic with maintaining 
the circuit Integrity. 

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As I believe this has been a 
major issue. 

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Reported in the literature that 
is correct. 

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It's been very challenging. 
There are patient, related, 

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factors and technique factors 
that make this so challenging 

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the patient related factors of 
course, are that these patients 

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often are hypercoagulable. 
And this can be from the 

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cytokine storm or other reasons.
During this time, we also wanted

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to limit nursing exposure and 
use of ppes. 

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So that related to issues with 
maintaining CRT circuit patency 

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also, for an instance, this 
meant Manipulations of the CRT 

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device. 
So you know, we had law firms 

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that lasted longer to prevent 
nurses from having to go 

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infrequently. 
We ourselves are institution, 

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use extension tubing. 
So all our CRT machines were 

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00:12:42,300 --> 00:12:46,600
outside the ICU rooms and 
because of that, this led to 

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00:12:46,600 --> 00:12:48,500
increase clotting of the 
circuit. 

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Other challenges, this patient 
population is use of prone 

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ventilation with issues with the
access placement. 

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You had lots of issues of access
dysfunction. 

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So how we manage these 
challenges? 

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Are all different ways. 
First of all, it's very 

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important that we ensured, a 
proper axis in the right IJ. 

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Many places. 
If they're using conductive 

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therapy made, sure they use 
higher blood flows to decrease 

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the filtration fraction or even 
convert it to diffusive therapy.

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But I think what came out of 
this pandemics a realization 

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that these patients need 
anticoagulation there really has

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not been a single anticoagulant 
regimen that has been shown to 

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be better for these covid 
patients. 

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And people have tried all 
different things. 

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From Regional citrate 
anticoagulation to systemic 

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Heparin to thrombin Inhibitors. 
When we use the extensions, we 

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had to use a combination of 
citrate and heparin to keep the 

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circuit patent. 
And this was in predominantly 

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all our patients who had 
extensions. 

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When we stopped using the 
extensions, however, we were 

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successful in over 90% of our 
patients, keeping the circuit 

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Peyton just with citrate. 
So this has been great to see 

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how you adapted your 
anticoagulation and sir, get 

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strategies for the covid 
pandemic. 

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Finally, what would be your 
recommendations for clinicians 

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to optimize the effectiveness in
their own institutions? 

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Why I think it's always 
important to take into 

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consideration. 
All those circuit factors we 

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talked about you need a 
well-functioning, vascular 

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access if you're using 
convective therapies, higher 

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blood, flows, or using a pre 
dilutional fluid to reduce the 

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filtration fraction, making sure
you decrease the blood are 

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contact in the bubble trapped 
And promptly reacting to alarms.

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If you're using an anticoagulant
Regional citrate, 

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anticoagulation RCA is 
recommended if you have the 

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expertise or the availability of
the solution regardless of 

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whatever anticoagulant you're 
using. 

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It's really important to have 
standardized protocols in order 

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sets because those are the keys 
for multidisciplinary management

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and then you have to have a 
quality improvement program, you

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need to monitor the downtime and
I periodic measurement of solute

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clearance to ensure that you're 
providing good therapy and 

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delivering CRT as it should be 
delivered with that. 

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Take me in mind, I want to thank
my guest. 

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Dr. Ashida to Ronnie for joining
me to discuss best practices on 

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anticoagulation and citrate used
during CRT doctor through money.

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It was great having you on the 
program. 

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Thank you so much. 
It was a privilege being here 

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today. 
I'm dr. 

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Ravi mantha to access this and 
other episodes in our series 

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visit KD go. 
Dot org. 

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Slash what Cass? 
Thanks for listening this 

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00:15:34,600 --> 00:15:37,600
episode of que digo 
conversations in Nephrology was 

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00:15:37,600 --> 00:15:41,600
provided by KD go and supported 
by Baxter Healthcare.