The Acid-Base Effect of Changing Citrate Solution for Regional Anticoagulation during Continuous Veno-Venous Hemofiltration

Abstract

(Int J Artif Organs 2008; 31: 228-36)

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

“…Egi et al found that increasing the citrate dose during RCA-CVVH significantly attenuated magnitude and duration of metabolic acidosis [9]. When administering respectively 11 and 14 mmol/L citrate (ie a SIDa of respectively 33 and 42 mmol/L), they observed an alkalinizing effect depending on the SIDa of the replacement fluid and an acidifying effect due to an increase in unmeasured anions [9, 17].…”

“…When administering respectively 11 and 14 mmol/L citrate (ie a SIDa of respectively 33 and 42 mmol/L), they observed an alkalinizing effect depending on the SIDa of the replacement fluid and an acidifying effect due to an increase in unmeasured anions [9, 17]. The highly different citrate flow between groups (1.83 vs. 3.10 mmol/L blood, 22 vs. 28 mmol/h, and 520 vs. 672 mmol/day) might explain the observed alkalinizing effect [9].…”

“…When administering respectively 11 and 14 mmol/L citrate (ie a SIDa of respectively 33 and 42 mmol/L), they observed an alkalinizing effect depending on the SIDa of the replacement fluid and an acidifying effect due to an increase in unmeasured anions [9, 17]. The highly different citrate flow between groups (1.83 vs. 3.10 mmol/L blood, 22 vs. 28 mmol/h, and 520 vs. 672 mmol/day) might explain the observed alkalinizing effect [9]. Compared with our patients, hyperchloremic metabolic acidosis did not occur as the difference in chloride flow was less pronounced (18 vs.16.5 mmol/L blood) for a chloride content of 108 vs. 99 mmol /L [9, 11].…”

“…Egi et al were the first to document changes in acid-base balance in patients undergoing RCA-CVVH [9]. Since then, many attempts were undertaken to find the optimal citrate solution that allowed swift and effective control of acidosis whilst avoiding rebound alkalosis during continuous renal replacement therapy (CRRT) [10, 11].…”

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

“…Obviously, it is directly linked to the increased SID due to the significant load of sodium from trisodium citrate, during citrate metabolization. Egi et al [8] compared a C14 with a C11 solution (also low concentration or diluted citrate) and found more metabolic alkalosis in the C14 arm. Daily infused citrate was higher in patients receiving C14, which translated into a corresponding additional bicarbonate load that shifted acid-base balance toward metabolic alkalosis.…”