Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy in the Perioperative Care of Liver Transplant Recipients: A Single Center Experience

Kidney injury with concomitant hemodialysis is a common finding in perioperative care of liver transplant patients. The aim of this study was to evaluate disturbances in acid-base status, electrolyte balance and citrate accumulation during hemodialysis with regional citrate anticoagulation in perioperative care of liver transplant recipients. A retrospective, single center evaluation was conducted of patients with severe liver dysfunction receiving renal replacement therapy in the perioperative care of liver transplantation in a multidisciplinary ICU of a university hospital. Within 5 days of ICU stay, 89 patients undergoing liver transplantation received regional citrate anticoagulation for hemodialysis. During the study period pH (7.39 [7.33/7.43] vs. 7.44 [7.39/7.47], P-value=0.014), base excess values (-0.9 [-5.08/2.35] vs. 4.3 [1.93/8.21], P-value=0.001) and standard bicarbonate (23.6 [20/26.9] vs. 28.2 [26.2/32.2], P-value=0.001) significantly increased, whereas lactate levels (2.6 [1.60/4.45] vs. 1.25 [0.98/1.9], P-value=0.071) and Ca-tot/Ca-ion-ratio decreased or remained below the upper reference. Hypocalcemia appeared mostly within 48h after dialysis initiation. Although sodium levels increased during the observation, rates of hypernatremia were comparable between hemodialysis days 1 and 5. Hemodialysis using regional citrate anticoagulation remains a challenge in the perioperative care of liver transplant recipients. Major attention must be paid to acid-base disturbances and citrate accumulation within 48h after dialysis initiation. Nevertheless, regional citrate anticoagulation in liver dysfunction is a feasible and valuable tool, when limitations and pitfalls are adequately considered.