Bicarbonate-based haemofiltration in the management of acute renal failure with lactic acidosis

Abstract

Continuous haemofiltration with lactate-based replacement fluid is widely used for the treatment of acute renal failure (ARF). In the presence of lactic acidosis, such treatment exacerbates rather than improves the clinical state. Continuous haemofiltration using a locally-prepared bicarbonate-based replacement fluid was performed in 200 patients over 7 years. All the patients had ARF with concomitant lactic acidosis, or demonstrated lactate intolerance after starting haemofiltration with lactate-based replacement fluids. In every case it was possible to correct the acidosis without inducing either extracellular volume expansion or hypernatraemia. In 89 patients (45%), the lactic acidosis resolved while being treated with bicarbonate-based haemofiltration. Fifty-seven patients (28.5%) survived. Significant differences at presentation in the group who survived, compared with those who died, were seen in age (50.8 vs. 57.1), mean arterial pressure (68.5 vs. 60.0 mmHg) and APACHE II score (32.1 vs. 38.9). Neither the severity of the presenting acidosis nor the arterial blood lactate appeared to predict outcome. Patients who developed ARF and lactic acidosis after cardiac surgery had a low survival rate. The combination of ARF and lactic acidosis that cannot safely be treated by haemofiltration using lactate-based replacement fluids can be managed with bicarbonate-based haemofiltration.

Do Bicarbonate-Based Solutions for Continuous Renal Replacement Therapy Offer Better Control of Metabolic Acidosis than Lactate-Containing Fluids?

“…However, there was no increase in blood pressure or reduction in pressor requirements. The administration of lactate-based solutions has been reported to lead to an increase in blood lactate [15], but in our study blood and ultrafiltrate lactate concentrations were not different between the groups. We found that base excess was more rapidly corrected with bicarbonate fluids compared to lactate.…”

Acid-Base and Electrolyte Management in Continuous Renal Replacement Therapy

“…Hilton et al [10] have shown that use of bicarbonatebased solutions is associated with improved hemodynamic stability although no difference was found by Thomas et al [11] comparing lactate-and bicarbonate-based solutions. A recently completed multicenter study in Germany has further shown that use of lactate-based substitution fluids is associated with reduced hemodynamic stability in comparison to bicarbonate-based solutions [16].…”

Lactic Acidosis in a Patient with Type 2 Diabetes Mellitus

“…Almost all involve continuous RRT (CRRT). Early uncontrolled studies showed the feasibility of CRRT modalities in the treatment of patients with renal failure and lactic acidosis (45)(46)(47) and emphasized the metabolic advantage of bicarbonate-over lactatebuffered dialysate (46). A recent single-center observational cohort study of 116 patients with AKI and lactic acidosis showed that CRRT using bicarbonate-buffered fluids can reduce blood lactate levels and raise pH (48).…”