Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients
Regional citrate anticoagulation is safe, feasible and increasingly used in critically ill patients on continuous renal replacement therapy (CRRT). However, in patients with hepatic or multi-organ dysfunction, citrate accumulation may lead to an imbalance of calcium homeostasis. The study aimed at e...
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| Veröffentlicht in: | Critical care (London, England) England), 2012-05, Vol.16 (3), p.R97-R97, Article R97 |
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| creator | Link, Andreas Klingele, Matthias Speer, Timo Rbah, Ranja Pöss, Janine Lerner-Gräber, Anne Fliser, Danilo Böhm, Michael |
| description | Regional citrate anticoagulation is safe, feasible and increasingly used in critically ill patients on continuous renal replacement therapy (CRRT). However, in patients with hepatic or multi-organ dysfunction, citrate accumulation may lead to an imbalance of calcium homeostasis. The study aimed at evaluating the incidence and prognostic relevance of an increased total to ionized calcium ratio (T/I Ca(2+) ratio) and its association to hepatic dysfunction.
We performed a prospective observational study on n = 208 critically ill patients with acute kidney injury (AKI) and necessity for CRRT with regional citrate anticoagulation (CRRT-citrate) between September 2009 and September 2011. Critical illness was estimated by Simplified Acute Physiology Score II; hepatic function was measured with indocyanine green plasma disappearance rate. After achieving a steady state of calcium homeostasis patients were classified into tertiles according to the T/I Ca(2+) ratio ( |
| doi_str_mv | 10.1186/cc11363 |
| format | Article |
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We performed a prospective observational study on n = 208 critically ill patients with acute kidney injury (AKI) and necessity for CRRT with regional citrate anticoagulation (CRRT-citrate) between September 2009 and September 2011. Critical illness was estimated by Simplified Acute Physiology Score II; hepatic function was measured with indocyanine green plasma disappearance rate. After achieving a steady state of calcium homeostasis patients were classified into tertiles according to the T/I Ca(2+) ratio (<2.0 versus 2.0 - 2.39 versus ≥ 2.4).
The T/I Ca(2+) ratio was determined as an independent predictor for 28-day mortality in critically ill patients with AKI on CRRT-citrate confirmed by receiver operating characteristics and multivariate analysis (Area under the curve 0.94 ± 0.02; p<0.001). A T/I Ca(2+) ratio ≥ 2.4 independently predicted a 33.5-fold (p<0.001) increase in 28-day mortality-rate. There was a significant correlation between the T/I Ca(2+) ratio and the hepatic clearance (p<0.001) and the severity of critical illness (p<0.001). The efficacy and safety of citrate anticoagulation, determined by blood urea nitrogen, mean filter patency and bleeding episodes, were not significantly different between the tertiles.
In patients on CRRT-citrate T/I Ca(2+) ratio is closely related to the clinical outcome and emerged as an independent predictor of 28-day mortality. Larger studies are required to define the cut-off and predictive value for the T/I Ca(2+) ratio. This ratio is associated with hepatic and/or multi-organ dysfunction and therefore an important therapeutic target.</description><identifier>ISSN: 1364-8535</identifier><identifier>EISSN: 1466-609X</identifier><identifier>EISSN: 1364-8535</identifier><identifier>DOI: 10.1186/cc11363</identifier><identifier>PMID: 22643456</identifier><language>eng</language><publisher>England: BioMed Central Ltd</publisher><subject>Aged ; Analysis ; Anticoagulants (Medicine) ; Anticoagulants - therapeutic use ; Calcium - blood ; Calcium, Dietary ; Citric Acid - therapeutic use ; Critical Illness - therapy ; Evidence-based medicine ; Female ; Humans ; Male ; Measurement ; Medical research ; Medicine, Experimental ; Middle Aged ; Mortality ; Mortality - trends ; Predictive Value of Tests ; Prospective Studies ; Renal Replacement Therapy - methods ; Renal Replacement Therapy - mortality ; Urea</subject><ispartof>Critical care (London, England), 2012-05, Vol.16 (3), p.R97-R97, Article R97</ispartof><rights>COPYRIGHT 2012 BioMed Central Ltd.</rights><rights>Copyright ©2012 Link et al.; licensee BioMed Central Ltd. 2012 Link et al.; licensee BioMed Central Ltd.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-b487t-e8e451d9fe5d5c650aa0ff865c698ec37f9501e37fbf71d02e10b1ed537c29963</citedby><cites>FETCH-LOGICAL-b487t-e8e451d9fe5d5c650aa0ff865c698ec37f9501e37fbf71d02e10b1ed537c29963</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580644/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580644/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,27924,27925,53791,53793</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/22643456$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Link, Andreas</creatorcontrib><creatorcontrib>Klingele, Matthias</creatorcontrib><creatorcontrib>Speer, Timo</creatorcontrib><creatorcontrib>Rbah, Ranja</creatorcontrib><creatorcontrib>Pöss, Janine</creatorcontrib><creatorcontrib>Lerner-Gräber, Anne</creatorcontrib><creatorcontrib>Fliser, Danilo</creatorcontrib><creatorcontrib>Böhm, Michael</creatorcontrib><title>Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients</title><title>Critical care (London, England)</title><addtitle>Crit Care</addtitle><description>Regional citrate anticoagulation is safe, feasible and increasingly used in critically ill patients on continuous renal replacement therapy (CRRT). However, in patients with hepatic or multi-organ dysfunction, citrate accumulation may lead to an imbalance of calcium homeostasis. The study aimed at evaluating the incidence and prognostic relevance of an increased total to ionized calcium ratio (T/I Ca(2+) ratio) and its association to hepatic dysfunction.
We performed a prospective observational study on n = 208 critically ill patients with acute kidney injury (AKI) and necessity for CRRT with regional citrate anticoagulation (CRRT-citrate) between September 2009 and September 2011. Critical illness was estimated by Simplified Acute Physiology Score II; hepatic function was measured with indocyanine green plasma disappearance rate. After achieving a steady state of calcium homeostasis patients were classified into tertiles according to the T/I Ca(2+) ratio (<2.0 versus 2.0 - 2.39 versus ≥ 2.4).
The T/I Ca(2+) ratio was determined as an independent predictor for 28-day mortality in critically ill patients with AKI on CRRT-citrate confirmed by receiver operating characteristics and multivariate analysis (Area under the curve 0.94 ± 0.02; p<0.001). A T/I Ca(2+) ratio ≥ 2.4 independently predicted a 33.5-fold (p<0.001) increase in 28-day mortality-rate. There was a significant correlation between the T/I Ca(2+) ratio and the hepatic clearance (p<0.001) and the severity of critical illness (p<0.001). The efficacy and safety of citrate anticoagulation, determined by blood urea nitrogen, mean filter patency and bleeding episodes, were not significantly different between the tertiles.
In patients on CRRT-citrate T/I Ca(2+) ratio is closely related to the clinical outcome and emerged as an independent predictor of 28-day mortality. Larger studies are required to define the cut-off and predictive value for the T/I Ca(2+) ratio. This ratio is associated with hepatic and/or multi-organ dysfunction and therefore an important therapeutic target.</description><subject>Aged</subject><subject>Analysis</subject><subject>Anticoagulants (Medicine)</subject><subject>Anticoagulants - therapeutic use</subject><subject>Calcium - blood</subject><subject>Calcium, Dietary</subject><subject>Citric Acid - therapeutic use</subject><subject>Critical Illness - therapy</subject><subject>Evidence-based medicine</subject><subject>Female</subject><subject>Humans</subject><subject>Male</subject><subject>Measurement</subject><subject>Medical research</subject><subject>Medicine, Experimental</subject><subject>Middle Aged</subject><subject>Mortality</subject><subject>Mortality - trends</subject><subject>Predictive Value of Tests</subject><subject>Prospective Studies</subject><subject>Renal Replacement Therapy - methods</subject><subject>Renal Replacement Therapy - mortality</subject><subject>Urea</subject><issn>1364-8535</issn><issn>1466-609X</issn><issn>1364-8535</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2012</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1ks9q3DAQxk1paNK09A2KoIf24lSyLNnuoRBC-gcCvaTQm5Dl8a6KLLmS3LJ5i7xxZrvbkIUUgWaY-b6fxEhF8YrRM8Za-d4YxrjkT4oTVktZStr9eIo5l3XZCi6Oi-cp_aSUNa3kz4rjqpI1r4U8KW6vQ9auzKG0wdsbGIjRzthlIlFnG8gcYbAmJzKFiEKbN8R6YoLP1i9hSSSC1w732WkDE_hM8hqinjfkj81rYmxGEBCNBhP0anFbrP8LiRZr2jlEOkdmbKA9vSiORu0SvNzH0-L7p8vriy_l1bfPXy_Or8q-bptcQgu1YEM3ghiEkYJqTcexlZh3LRjejJ2gDDD2Y8MGWgGjPYNB8MZUXSf5afFxx52XfoLB4NlROzVHO-m4UUFbddjxdq1W4bfioqWyrhHwYQfobfgP4LBjwqT2D4Xmd_vTY_i1QMpqssmAc9oDjlUxIRitKsoblL7ZSVfagbJ-DEgzW7k6F7zmglZsqzp7RIVrgAkn72G0WD8wvN0ZTAwpRRjvb86o2n6qB3d9_XBS97p_v4jfAVZGzNI</recordid><startdate>20120529</startdate><enddate>20120529</enddate><creator>Link, Andreas</creator><creator>Klingele, Matthias</creator><creator>Speer, Timo</creator><creator>Rbah, Ranja</creator><creator>Pöss, Janine</creator><creator>Lerner-Gräber, Anne</creator><creator>Fliser, Danilo</creator><creator>Böhm, Michael</creator><general>BioMed Central Ltd</general><general>BioMed Central</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20120529</creationdate><title>Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients</title><author>Link, Andreas ; Klingele, Matthias ; Speer, Timo ; Rbah, Ranja ; Pöss, Janine ; Lerner-Gräber, Anne ; Fliser, Danilo ; Böhm, Michael</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-b487t-e8e451d9fe5d5c650aa0ff865c698ec37f9501e37fbf71d02e10b1ed537c29963</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2012</creationdate><topic>Aged</topic><topic>Analysis</topic><topic>Anticoagulants (Medicine)</topic><topic>Anticoagulants - therapeutic use</topic><topic>Calcium - blood</topic><topic>Calcium, Dietary</topic><topic>Citric Acid - therapeutic use</topic><topic>Critical Illness - therapy</topic><topic>Evidence-based medicine</topic><topic>Female</topic><topic>Humans</topic><topic>Male</topic><topic>Measurement</topic><topic>Medical research</topic><topic>Medicine, Experimental</topic><topic>Middle Aged</topic><topic>Mortality</topic><topic>Mortality - trends</topic><topic>Predictive Value of Tests</topic><topic>Prospective Studies</topic><topic>Renal Replacement Therapy - methods</topic><topic>Renal Replacement Therapy - mortality</topic><topic>Urea</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Link, Andreas</creatorcontrib><creatorcontrib>Klingele, Matthias</creatorcontrib><creatorcontrib>Speer, Timo</creatorcontrib><creatorcontrib>Rbah, Ranja</creatorcontrib><creatorcontrib>Pöss, Janine</creatorcontrib><creatorcontrib>Lerner-Gräber, Anne</creatorcontrib><creatorcontrib>Fliser, Danilo</creatorcontrib><creatorcontrib>Böhm, Michael</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Critical care (London, England)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Link, Andreas</au><au>Klingele, Matthias</au><au>Speer, Timo</au><au>Rbah, Ranja</au><au>Pöss, Janine</au><au>Lerner-Gräber, Anne</au><au>Fliser, Danilo</au><au>Böhm, Michael</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients</atitle><jtitle>Critical care (London, England)</jtitle><addtitle>Crit Care</addtitle><date>2012-05-29</date><risdate>2012</risdate><volume>16</volume><issue>3</issue><spage>R97</spage><epage>R97</epage><pages>R97-R97</pages><artnum>R97</artnum><issn>1364-8535</issn><eissn>1466-609X</eissn><eissn>1364-8535</eissn><abstract>Regional citrate anticoagulation is safe, feasible and increasingly used in critically ill patients on continuous renal replacement therapy (CRRT). However, in patients with hepatic or multi-organ dysfunction, citrate accumulation may lead to an imbalance of calcium homeostasis. The study aimed at evaluating the incidence and prognostic relevance of an increased total to ionized calcium ratio (T/I Ca(2+) ratio) and its association to hepatic dysfunction.
We performed a prospective observational study on n = 208 critically ill patients with acute kidney injury (AKI) and necessity for CRRT with regional citrate anticoagulation (CRRT-citrate) between September 2009 and September 2011. Critical illness was estimated by Simplified Acute Physiology Score II; hepatic function was measured with indocyanine green plasma disappearance rate. After achieving a steady state of calcium homeostasis patients were classified into tertiles according to the T/I Ca(2+) ratio (<2.0 versus 2.0 - 2.39 versus ≥ 2.4).
The T/I Ca(2+) ratio was determined as an independent predictor for 28-day mortality in critically ill patients with AKI on CRRT-citrate confirmed by receiver operating characteristics and multivariate analysis (Area under the curve 0.94 ± 0.02; p<0.001). A T/I Ca(2+) ratio ≥ 2.4 independently predicted a 33.5-fold (p<0.001) increase in 28-day mortality-rate. There was a significant correlation between the T/I Ca(2+) ratio and the hepatic clearance (p<0.001) and the severity of critical illness (p<0.001). The efficacy and safety of citrate anticoagulation, determined by blood urea nitrogen, mean filter patency and bleeding episodes, were not significantly different between the tertiles.
In patients on CRRT-citrate T/I Ca(2+) ratio is closely related to the clinical outcome and emerged as an independent predictor of 28-day mortality. Larger studies are required to define the cut-off and predictive value for the T/I Ca(2+) ratio. This ratio is associated with hepatic and/or multi-organ dysfunction and therefore an important therapeutic target.</abstract><cop>England</cop><pub>BioMed Central Ltd</pub><pmid>22643456</pmid><doi>10.1186/cc11363</doi><oa>free_for_read</oa></addata></record> |
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| subjects | Aged Analysis Anticoagulants (Medicine) Anticoagulants - therapeutic use Calcium - blood Calcium, Dietary Citric Acid - therapeutic use Critical Illness - therapy Evidence-based medicine Female Humans Male Measurement Medical research Medicine, Experimental Middle Aged Mortality Mortality - trends Predictive Value of Tests Prospective Studies Renal Replacement Therapy - methods Renal Replacement Therapy - mortality Urea |
| title | Total-to-ionized calcium ratio predicts mortality in continuous renal replacement therapy with citrate anticoagulation in critically ill patients |
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