Bioenergetic gain of citrate-anticoagulated continuous renal replacement therapy

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 deliveryis 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.