# Safety and Efficacy of Citrate Anticoagulation in Therapeutic Plasma Exchange: A Clinical Study

## TL;DR

This study shows that citrate anticoagulation is a safe and effective alternative to heparin during therapeutic plasma exchange, especially for patients at high risk of clotting.

## Contribution

The study demonstrates the safety and efficacy of citrate anticoagulation in therapeutic plasma exchange, particularly in high-risk patients.

## Key findings

- Citrate anticoagulation successfully prevented circuit clotting in 21 out of 23 high-risk TPE sessions.
- 27 out of 29 TPE sessions using citrate from the start were completed successfully in hypercoagulable patients.
- No cases of citrate toxicity were observed in the study.

## Abstract

Introduction: TPE (therapeutic plasma exchange) has proven to be an extremely effective treatment for a range of conditions, especially over the past 20 years. Anticoagulation with heparin is currently the accepted recommendation for therapeutic plasma exchange sessions. However, the hypercoagulable state and hyperviscosity in some patients requiring TPE present a challenge, particularly during the first session, due to an increased risk of circuit clotting. Citrate anticoagulation has been proposed for extracorporeal therapies such as hemodiafiltration where heparin is contraindicated. Nevertheless, citrate anticoagulation is still generally avoided in patients undergoing TPE. Materials and Methods: A total of 26 patients underwent 52 TPE sessions using citrate. Fifteen patients received citrate from the beginning of therapy, accounting for 29 sessions, and eleven patients were switched to citrate after initially starting with heparin, when an imminent risk of circuit clotting quickly became evident—23 sessions in total. The imminent risk of circuit clotting was assessed by a continuous and accelerated increase in transmembrane pressure despite heparin anticoagulation. The effectiveness of citrate anticoagulation and its safety for patients were evaluated. Results: Of the 23 sessions where there was a risk of circuit clotting, citrate was added on top of heparin in those sessions; 21 sessions were successfully completed. It can be said that the kits were saved in these cases. Among the 29 TPE sessions that used citrate from the start, 27 were completed successfully, even though the patients were considered to have a hypercoagulable status. No cases of citrate toxicity were identified. Conclusions: TPE with citrate is a safe option for patients. It can preserve TPE kits from the beginning or during treatment in patients with hypercoagulability. Citrate can be also be used when heparin is contraindicated or ineffective.