Chloride content of solutions used for regional citrate anticoagulation might be responsible for blunting correction of metabolic acidosis during continuous veno-venous hemofiltration

Abstract

BackgroundCitrate, the currently preferred anticoagulant for continuous veno-venous hemofiltration (CVVH), may influence acid-base equilibrium.MethodsThe effect of 2 different citrate solutions on acid-base status was assessed according to the Stewart-Figge approach in two consecutive cohorts of critically ill adult patients. The first group received Prismocitrate 10/2 (PC10/2; 10 mmol citrate/L). The next group was treated with Prismocitrate 18/0 (PC18; 18 mmol citrate/L). Both groups received bicarbonate-buffered fluids in post-dilution.ResultsAt similar citrate flow, the metabolic acidosis present at baseline in both groups was significantly attenuated in PC18 patients but persisted in PC10/2 patients after 24 h of treatment (median pH 7,42 vs 7,28; p = 0.0001). Acidosis in the PC10/2 group was associated with a decreased strong ion difference and an increased strong ion gap (respectively 43 vs. 51 mmol/L and 17 vs. 12 mmol/L, PC10/2 vs. PC18; both p = 0.001). Chloride flow was higher in PC10/2 than in PC18 subjects (25.9 vs 14.3 mmol/L blood; p < 0.05).ConclusionCorrection of acidosis was blunted in patients who received 10 mmol citrate/L as regional anticoagulation during CVVH. This could be explained by differences in chloride flow between the applied citrate solutions inducing hyperchloremic acidosis.

Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation – An observational case-control stud

“…In contrast to our results, Khadzhynov and others found that the bicarbonate concentration and base excess were below the normal ranges (69.9% and 84.6%, respectively) during RCA haemodiafiltration. Jacobs et al reported metabolic alkalosis (pH >7.5) in 10% of patients treated with pre-dilution CVVH RCA in the group of patients treated with Prismocitrate 18 solution in contrast to its absence in patients treated with Prismocitrate 10/2 solution (Jacobs et al, 2016). Since our data collection, the protocol recommended by Nikkiso changed the starting dose from 35 ml/kg/h to 25 ml/kg/h, which results in decreased citrate dose and might lead to lower incidence of both metabolic alkalosis and hypocalcaemia.…”

Ionic Homeostasis, Acid-base Balance and the Risk of Citrate Accumulation in Patients After Cardiovascular Surgery Treated With Continuous Veno-venous Haemofiltration With Post-dilution Regional Citrate Anticoagulation

“…As also reported in previous studies, the results of our study indicated that most speci c RCA protocols can cause upward or downward trends in bicarbonate concentrations and base excess. Jacobs et al reported metabolic alkalosis (pH > 7.5) in 10% of patients treated with pre-dilution CVVH RCA in the group of patients treated with Prismocitrate 18 solution in contrast to its absence in patients treated with Prismocitrate 10/2 solution [29].…”

Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: All Citrates Are Not Created Equal!

“…Yet, the C18 solution contained more sodium (152 vs.143 mmol/l), resulting in higher sodium levels throughout the study. This relative 'hypernatremia' significantly increased SIDa uncovering metabolic alkalosis [2,5,7] . Counteracting metabolic alkalosis thus depends on the inciting culprit.…”

“…Metabolic alkalosis, however, may also be related to the electrolyte composition of the chosen citrate liquids. Patients who received C18 in the Jacobs et al [7] study developed hypochloremic metabolic alkalosis, which stemmed from the lower chloride content of the C18 as compared with the C10/2 solution (86 vs. 106 mmol/l). In the BEaRRS study, the 2 studied citrate solutions had similar chloride content (99 mmol/l).…”

“…Jacobs et al [6,7] Jacobs/Honore/Hendrickx/Spapen Blood Purif 2016;42:219-220 DOI: 10.1159/000448801 220 tution into 'acidifying' normal saline may be a good option to blunt metabolic alkalosis, at least in the CVVH mode [7] . Nonetheless, a word of caution should be mentioned regarding this latter option.…”