Copper, selenium, zinc, and thiamine balances during continuous venovenous hemodiafiltration in critically ill patients

Berger, Mette M.; Shenkin, Alan; Revelly, Jean-Pierre; Roberts, E.; Cayeux, Marie-Christine; Baines, Malcolm G.; Chioléro, René

doi:10.1093/ajcn/80.2.410

Cited by 217 publications

(172 citation statements)

References 22 publications

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“…First, high-intensity CRRT removes more beneficial substances, counteracting the beneficial removal of harmful compounds. Beneficial substances include micronutrients such as water-soluble vitamins, trace elements, amino acids and circulating beneficial mediators of whatever kind [23,24]. In particular, hypophosphatemia may play a role as its incidence was increased by highintensity CRRT in the original trial from which the current nested cohort was taken [7].…”

Section: Survivalmentioning

confidence: 99%

How to explain and exploit the beneficial effects of high-volume hemofiltration on hemodynamics and strong ion gap

Straaten

Elbers

2013

Intensive Care Med

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Early high-volume hemofiltration has been suggested as adjuvant treatment for critically ill patients with severe septic shock to stabilize the circulation [1]. Several nonrandomized clinical and animal studies have shown a benefit [2]. The rationale for this treatment is that within the setting of an overwhelming inflammatory response, pro-and antiinflammatory mediators can be removed [3] and homeostasis restored [4]. Grootendorst et al. [5] had already found that substance removal by hemofiltration likely plays a role, because the infusion of ultrafiltrate from endotoxemic pigs depresses myocardial performance in normal pigs, while the infusion of ultrafiltrate from healthy pigs does not. However, a recent meta-analysis including randomized controlled trials and subgroups from randomized controlled trials was not able to show any benefit of continuous renal replacement therapy (CRRT) versus no CRRT or a higher dose of CRRT in patients with severe sepsis or septic shock in terms of survival, hemodynamics, pulmonary gas exchange, organ failure and length of stay [6]. The effect of CRRT on survival was not modified by CRRT dose. This was recently confirmed by a large randomized controlled trial [7].Bellomo et al. [8] now specifically report on data from this trial from a nested cohort of 115 patients from two of the participating ICUs. Patients were treated with venovenous hemodiafiltration of either low intensity (with effluent flow at 25 ml/kg/h) or high intensity (at 40 ml/kg/ h). They focused on the control of metabolic acidosis, mean arterial blood pressure and noradrenaline dose and their relationship during the first 24 h of treatment. They found that pH and traditional markers of the metabolic component of acid base balance, i.e. bicarbonate and base excess similarly improved in both groups. However, in the high-intensity arm, lactate and in particular the strong ion gap (SIG) decreased significantly, concomitantly with an increase in mean arterial blood pressure and a decreased noradrenaline dose. These improvements were not observed in the low-intensity arm.These results may be of clinical importance. But how do we explain and more importantly how do we exploit them? Substance removal and reversal of hypotensionHigh-intensity CRRT likely removes more inflammatory mediators than the low-intensity modality. However, the removal of cytokines is often not sufficient to decrease plasma concentrations [9]. The reasons may be the high size and low free fraction of the cytokines, and the higher rate of production compared to removal. In contrast, freecirculating mediators in the middle molecular range, such as complement factors [1], prostaglandins and leukotrienes [10], and myocardial depressant factors [11] are removed [12,13].In the present study, SIG significantly decreased in the high-intensity group, which was not the case in the lowintensity group. This may indicate that substance removal contributed to improved hemodynamics. In this setting, SIG likely represents unmeasured strong anions.

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Section: Survivalmentioning

confidence: 99%

How to explain and exploit the beneficial effects of high-volume hemofiltration on hemodynamics and strong ion gap

Straaten

Elbers

2013

Intensive Care Med

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“…Effluent losses of copper during CRRT are about 400 µg/d [39,40]. This is nearly 50% of the DRI and falls well within the recommended parenteral intake range of 300 to 500 µg/d [41].…”

mentioning

confidence: 53%

“…Selenium in CRRT fluids is negligible but losses in CRRT effluent have been observed in the range of 35 to 91 µg/d [39,40]. This amount is at or exceeds the DRI as well as the recommended parenteral intake of selenium [41].…”

mentioning

confidence: 97%

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Nutrition support therapy in acute kidney injury: Distinguishing dogma from good practice

Gervasio

Cotton²

2009

Curr Gastroenterol Rep

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!Acute kidney injury (AKI) is a frequently observed complication in critically ill patients. Its presentation may range from the early risk of renal dysfunction to complete renal failure. Morbidity and mortality in the AKI patient increase with the decline of renal function. Appropriate nutrition therapy is essential in the medical management of the AKI patient. Assessment of nutritional requirements should take into account the patient's underlying complication, comorbid medical conditions, and severity of the renal dysfunction. Various stages of AKI determine the direction of nutrition therapy. Additionally, understanding the macro-and micronutrient modifications and electrolyte and vitamin alterations that should be implemented are vital for better patient outcomes.

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“…Several studies have found thiamine deficiency to be prevalent in different critically ill conditions, such as prolonged parenteral nutrition, dialysis, post bariatric surgery, and burns. Importantly, thiamine deficiency is also prevalent in patients with septic shock, with rates ranging from 20% to 70%, depending on study design (7)(8)(9)(10). In addition, elevated concentrations of serum lactate, metabolic acidosis, and hypotension occur in both thiamine deficiency and septic shock.…”

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confidence: 99%

Thiamine as a metabolic resuscitator in septic shock: one size does not fit all

et al. 2016

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Copper, selenium, zinc, and thiamine balances during continuous venovenous hemodiafiltration in critically ill patients

Abstract: CRRT results in significant losses and negative balances of selenium, copper, and thiamine, which contribute to low plasma concentrations. Prolonged CRRT is likely to result in selenium and thiamine depletion despite supplementation at recommended amounts.

Cited by 217 publications

References 22 publications

How to explain and exploit the beneficial effects of high-volume hemofiltration on hemodynamics and strong ion gap

How to explain and exploit the beneficial effects of high-volume hemofiltration on hemodynamics and strong ion gap

Nutrition support therapy in acute kidney injury: Distinguishing dogma from good practice

Thiamine as a metabolic resuscitator in septic shock: one size does not fit all

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