Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration-a comparison between 2 citrate modalities and unfractionated heparin
Abstract
Purpose: To determine bioenergetic gain of 2 different citrate anticoagulated continuous hemodiafiltration (CVVHDF) modalities and a heparin modality. Materials and Methods: We compared the bio-energetic gain of citrate, glucose and lactate between 29 patients receiving 2.2% acid-citrate-dextrose with calcium-containing lactate-buffered solutions (ACD/Ca-plus/lactate), 34 on 4% trisodium citrate with calcium-free low-bicarbonate buffered fluids (TSC/Ca-min/bicarbonate), and 18 on heparin with lactate buffering (Hep/lactate).
Results: While delivered CVVHDF dose was about 2000 mL/h, total bioenergetic gain was 262kJ/h (IQR 230-284) with ACD/Ca-plus/lactate, 20 kJ/h (8-25) with TSC/Ca-min/bicarbonate (P < .01) and 60 kJ/h (52-76) with Hep/lactate. Median patient delivery of citrate was 31.2 mmol/h (25-34.7) in ACD/Ca-plus/lactate versus 14.8 mmol/h (12.4-19.1) in TSC/Ca-min/bicarbonate groups (P < .01).
Median delivery of glucose was 36.8 mmol/h (29.9-43) in ACD/Ca-plus/lactate, and of lactate 52.5 mmol/h (49.259.1) in ACD/Ca-plus/lactate and 56.1 mmol/h (49.6-64.2) in Hep/lactate groups. The higher energy delivery with ACD/Ca-plus/lactate was partially due to the higher blood flow used in this modality and the calcium-containing dialysate.
Conclusions: The bioenergetic gain of CVVHDF comes from glucose (in ACD), lactate and citrate. The amount substantially differs between modalities despite a similar CVVHDF dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a higher blood flow.
When calculating nutritional needs, we should account for the energy delivered by CVVHDF.