Source: Health Products Regulatory Authority (IE) Revision Year: 2022 Publisher: Fresenius Medical Care Deutschland GmbH, Else-Kröner-Straße 1, 61352 Bad Homburg v.d.H., Germany
Pharmacotherapeutic group: Haemodialytics and haemofiltrates, haemofiltrates
ATC code: B05ZB
Solution for RCA in CVVHD, CVVHDF, SLEDD and TPE.
RCA is a method to regionally anticoagulate blood in an extracorporeal circuit intended for blood purification, without having to use a systemic anticoagulant. RCA can be used in extracorporeal circuits that operate with low to moderate blood flows and where preferably a certain fraction of the citrate is removed by the blood purification treatment. Data from the scientific literature indicate that RCA may be used as a first-line anticoagulant in the indicated therapies; and may particularly benefit patients with active bleeding or at increased risk for bleeding. A higher degree of anticoagulation can usually be targeted compared to systemic anticoagulation, which benefits circuit patency and treatment efficacy.
Depending on the individual citrate-anticoagulated extracorporeal blood purification therapy, calcium is removed from the patient’s blood in variable quantity which makes calcium substitution necessary. Further, a part of the citrate infused for RCA unavoidably enters the patient’s systemic circulation with the re-transfused blood. This induces an increase of the systemic citrate concentration, which generally stabilises at a new level depending on the actual citrate infusion rate and the citrate metabolism in the liver and other tissues.
Calcium-citrate chelate complexes present in the patient’s blood dissociate when more citrate is metabolised than systemically infused. As a net effect, free ionised calcium remains in the patient’s blood and thereafter redistributes in the patient’s body where it is essential both for bone remodelling and as an electrolyte with crucial cellular functions throughout the body (e.g. in muscle cells and neurons).
Citrate is a normal metabolite in the human body and an intermediate substance in the Krebs cycle. This physiological pathway in conjunction with the respiratory chain is in the majority of patients capable of processing high amounts of citrate. The Krebs cycle takes place in the mitochondria, and all cells that contain these cellular organelles can metabolise citrate. Tissues rich in mitochondria such as liver, skeletal muscles, and kidney therefore have a higher capacity for citrate generation and elimination.
Absorption and distribution of sodium and citrate is determined by the patient’s clinical condition, metabolic status, and residual renal function.
In humans, citrate is an intermediate in the central metabolic pathway called Krebs cycle as mentioned above. Citrate is rapidly metabolised in several organs/tissues.
A substantial part of citrate is removed with the effluent. The amount of citrate being infused systemically is metabolised in most somatic cells.
There are no preclinical data of relevance to the prescriber.
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