Quantification of Systemic Delivery of Substrates for Intermediate Metabolism during Citrate Anticoagulation of Continuous Renal Replacement Therapy

Abstract

Background: There are limited data on systemic delivery of metabolic substrates during citrate anticoagulation. The direct citrate measurements are usually not available. Methods: Patients on 2.2% acid-citrate-dextrose (ACD, n = 41) were compared to a control group on unfractionated heparin (n = 17). All were treated on 1.9-m² polysulfone filters. Samples were taken from the central venous catheter, ports pre- and post-filter and from effluent. Results: The gain of citrate in CVVH (n = 18) was not different from CVVHDF (n = 23, p = 0.8). Mean gain of citrate was 25.4 ± 6.4 mmol/h. The systemic loads of lactate (p = 0.12) and glucose (p = 0.23) in CVVH were similar to CVVHDF. Mean inputs of lactate and glucose were 62.9 ± 21.1 and 26.6 ± 10.4 mmol/h, respectively. The mean difference between post- and prefilter unmeasured anions (d-UA) correlated with mean difference of citrate concentrations (p < 0.0001, r² = 0.66). The estimated caloric load of the citrate modalities was 5,536 ± 1,385 kJ/ 24 h. Conclusions: ACD might represent a significant load of metabolic substrates, particularly if used with lactate buffer. Systemic delivery of citrate can be predicted using d-UA in the extracorporeal circuit.