Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration—a comparison between 2 citrate modalities and unfractionated heparin

Borggrefe, Martin; Zakharchenko, M.; Leden, Pavel; Otáhal, Michal; Hrubý, Ján; Polák, F; Rusínová, Kateřina; Stach, Zdeněk; Tokarik, Monika; Vávrová, Jaroslava; Jabor, Antonı́n; Straaten, Heleen M. Oudemans–van

doi:10.1016/j.jcrc.2012.06.003

Cited by 40 publications

(63 citation statements)

References 28 publications

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“…In the absence of high lactate delivery, a substantial gain or loss of energy would not be expected from the replacement fluids because of the small difference in glucose concentrations between these fluids and blood. The only previous demonstration of energy gain with the use of citrate for anticoagulation to our knowledge is that from Balik et al (10,11), who reported that when an acid-citrate-dextrose solution is used with high lactate replacement fluids, CRRT can provide #1300 kcal/d. Our results are more relevant to the most recently published Improving Global Outcomes Acute Kidney Injury Work Group acute kidney injury guidelines (14), which recommend lactate-free replacement fluids.…”

Section: Discussionmentioning

confidence: 99%

“…In patients who require nutritional support, there is a strong relation between the amount of feeding administered and both hyperglycemia and insulin requirements (8). Continuous renal replacement therapy (CRRT) is now used universally in hemodynamically unstable individuals with acute and chronic kidney impairment, and it has been recognized as a potential source for macronutrient losses as well as macronutrient uptake, depending on the composition of the fluids used (9)(10)(11)(12). However, to our knowledge, the possibility for net macronutrient uptake has not been mentioned in published guidelines from nephrology and nutrition societies (13)(14)(15).…”

Section: Introductionmentioning

confidence: 99%

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Continuous renal replacement therapy: a potential source of calories in the critically ill,

New¹,

Nystrom²,

Frazee³

et al. 2017

The American Journal of Clinical Nutrition

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Background: Overfeeding can lead to multiple metabolic and clinical complications and has been associated with increased mortality in the critically ill. Continuous venovenous hemofiltration (CVVH) represents a potential source of calories that is poorly recognized and may contribute to overfeeding complications. Objective: We aimed to quantify the systemic caloric contribution of acid-citrate-dextrose regional anticoagulation and dextrosecontaining replacement fluids in the CVVH circuit. Design: This was a prospective study in 10 critically ill adult patients who received CVVH from April 2014 to June 2014. Serial pre-and postfilter blood samples (n = 4 each) were drawn and analyzed for glucose and citrate concentrations on each of 2 consecutive days. Results: Participants included 5 men and 5 women with a mean 6 SEM age of 61 6 4 y (range: 42-84 y) and body mass index (in kg/m 2 ) of 28 6 2 (range: 18.3-36.2). There was generally good agreement between data on the 2 study days (CV: 7-11%). Mean 6 SEM pre-and postfilter venous plasma glucose concentrations in the aggregate group were 152 6 10 and 178 6 9 mg/dL, respectively. Net glucose uptake from the CVVH circuit was 54 6 5 mg/min and provided 295 6 28 kcal/d. Prefilter plasma glucose concentrations were higher in patients with diabetes (n = 5) than in those without diabetes (168 6 12 compared with 140 6 14 mg/dL; P , 0.05); however, net glucose uptake was similar (46 6 8 compared with 61 6 6 mg/min; P = 0.15). Mean 6 SEM pre-and postfilter venous plasma citrate concentrations were 1 6 0.1 and 3.1 6 0.2 mmol/L, respectively. Net citrate uptake from the CVVH circuit was 60 6 2 mg/min and provided 218 6 8 kcal/d. Conclusions: During CVVH there was a substantial net uptake of both glucose and citrate that delivered exogenous energy and provided w512 kcal/d. Failure to account for this source of calories in critically ill patients receiving nutrition on CVVH may result in overfeeding.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Continuous renal replacement therapy: a potential source of calories in the critically ill,

New¹,

Nystrom²,

Frazee³

et al. 2017

The American Journal of Clinical Nutrition

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“…Finally, citrate also represents a source of carbohydratelike energy, providing 0.59 kcal/mmol (10,42). Thus, with the more commonly reported citrate protocols, which provide a citrate load of 11-20 mmol/h, the energy derived from citrate is approximately 150-280 kcal/24 h. Moreover, when anticoagulant citrate dextrose solution A (ACD-A) is used, which contains 2.5% dextrose, an additional caloric load is derived from dextrose metabolism (0.73 kcal/mmol), therefore providing 350-600 kcal/24 h. Lastly, in RCA protocols using lactate-buffered CRRT solutions, an additional supply of energy (500-600 kcal/24 h) may be derived from lactate (0.33 kcal/mmol).…”

Section: Rca: Basic Principles and Citrate Metabolismmentioning

confidence: 99%

“…Thus, with the more commonly reported citrate protocols, which provide a citrate load of 11-20 mmol/h, the energy derived from citrate is approximately 150-280 kcal/24 h. Moreover, when anticoagulant citrate dextrose solution A (ACD-A) is used, which contains 2.5% dextrose, an additional caloric load is derived from dextrose metabolism (0.73 kcal/mmol), therefore providing 350-600 kcal/24 h. Lastly, in RCA protocols using lactate-buffered CRRT solutions, an additional supply of energy (500-600 kcal/24 h) may be derived from lactate (0.33 kcal/mmol). Therefore, the energy delivered from RRT fluid components (both anticoagulation and replacement fluid) should be taken into account when calculating the nutritional needs of critically ill patients undergoing RRT (10,42,43).…”

Section: Rca: Basic Principles and Citrate Metabolismmentioning

confidence: 99%

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Morabito

Pistolesi

Tritapepe

et al. 2014

Clinical Journal of the American Society of Nephrology

124

130

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Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years.

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“…The energy delivered can differ substantially between modalities, even with comparable doses. 30 Such information should, therefore, be taken into account when nutritional needs are being calculated.…”

Section: Energy Gainmentioning

confidence: 99%

Risks and benefits of citrate anticoagulation for continuous renal replacement therapy

Shum¹,

Wu²,

Chan³

2014

Hong Kong Med J

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A B S T R A C THeparin, despite its significant side-effects, is the most commonly used anticoagulant for continuous renal replacement therapy in critical care setting. In recent years, citrate has gained much popularity by improving continuous renal replacement therapy circuit survival and decreasing blood transfusion requirements. However, its complex metabolic consequences warrant modification in the design of the citrate-based continuous renal replacement therapy protocol. With thorough understanding of the therapeutic mechanism of citrate, a simple and practicable protocol can be devised. Citratebased continuous renal replacement therapy can

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Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration—a comparison between 2 citrate modalities and unfractionated heparin

Cited by 40 publications

References 28 publications

Continuous renal replacement therapy: a potential source of calories in the critically ill,

Continuous renal replacement therapy: a potential source of calories in the critically ill,

Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

Risks and benefits of citrate anticoagulation for continuous renal replacement therapy

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