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Bioenergetic Gain of Citrate-Anticoagulated Continuous Renal Replacement Therapy

Living reference work entry

Abstract

The cumulative evidence indicating both efficacy and safety of regional citrate anticoagulation (RCA) has been reflected in recent KDIGO guidelines suggesting the use of citrate for prevention of filter clotting in preference to standard heparin, even in patients without an increased bleeding risk. In this chapter we discuss homeostatic consequences of various citrate modalities and bioenergetic gains of various forms of citrate-based continuous renal replacement therapy (CRRT). A systemic dosage of citrate depends on the balance between citrate flow related directly to blood flow and citrate elimination in the effluent which is related to a set RRT dosage. The citrate dosage and systemic energetic delivery is also influenced by the presence or absence of calcium in dialysis/substitution fluids which may be bicarbonate or lactate buffered. Associated homeostatic changes in acid-base regulation and ion changes develop parallely to energetic deliveries given by the loads of citrate, lactate, and glucose. In summary, the bioenergetic gain of CRRT comes from glucose (in acid-citrate-dextrose, ACD), lactate (buffer), and citrate (anticoagulant). The amount substantially differs between modalities despite a similar CRRT dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a non-reduced ordinary blood flow. When calculating nutritional needs, we should account for the energy delivered by CRRT.

Keywords

Continuous Renal Replacement Therapy Metabolic Alkalosis Trisodium Citrate Extracorporeal Circuit RCARegional Citrate Anticoagulation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

List of Abbreviations

ACD

Acid-citrate-dextrose

CRRT

Continuous renal replacement therapy

CVVH

Continuous venovenous hemofiltration

CVVHDF

Continuous venovenous hemodiafiltration

EDD

Extended daily dialysis

KDIGO

Kidney disease improving global outcomes

Qb

Blood flow

Qc

Citrate flow

Qd

Dialysis flow

Qeff

Effluent flow

Qpost

Postfilter blood flow

Qpre

Prefilter blood flow

TSC

Trisodium citrate

UF

Ultrafiltration

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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of Anaesthesiology and Intensive Care, First Faculty of MedicineCharles University and General University HospitalPrague 2Czech Republic

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