Continuous venovenous hemodiafiltration with a low citrate dose regional anticoagulation protocol and a phosphate-containing solution: effects on acid–base status and phosphate supplementation needs

BMC Nephrology

Alessandro Pierucci¹  Enrico Fiaccadori²  Francesca Polistena¹  Laura Zeppilli¹  Elio Vitaliano⁴  Luigi Tritapepe³  Valentina Pistolesi¹  Santo Morabito¹ 

[1] Department of Nephrology and Urology, Hemodialysis Unit, Umberto I, Policlinico di Roma, “Sapienza” University, Rome, Italy;Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University, Parma, Italy;Department of Anesthesiology and Intensive Care, Cardiac Surgery ICU, Umberto I, Policlinico di Roma, “Sapienza” University, Rome, Italy;Division of Nephrology and Dialysis, Pertini Hospital, Rome, Italy

关键词: Regional citrate anticoagulation;    Hypophosphatemia;    CVVHDF;    CVVH;    CRRT;    Citrate;    AKI;   

Others  :  1082807
DOI  :  10.1186/1471-2369-14-232

 received in 2013-05-16, accepted in 2013-10-22,  发布年份 2013

【 摘 要 】

Background

Recent guidelines suggest the adoption of regional citrate anticoagulation (RCA) as first choice CRRT anticoagulation modality in patients without contraindications for citrate. Regardless of the anticoagulation protocol, hypophosphatemia represents a potential drawback of CRRT which could be prevented by the adoption of phosphate-containing CRRT solutions. The aim was to evaluate the effects on acid–base status and phosphate supplementation needs of a new RCA protocol for Continuous Venovenous Hemodiafiltration (CVVHDF) combining the use of citrate with a phosphate-containing CRRT solution.

Methods

To refine our routine RCA-CVVH protocol (12 mmol/l citrate, HCO₃^- 32 mmol/l replacement fluid) (protocol A) and to prevent CRRT-related hypophosphatemia, we introduced a new RCA-CVVHDF protocol (protocol B) combining an 18 mmol/l citrate solution with a phosphate-containing dialysate/replacement fluid (HCO₃^- 30 mmol/l, Phosphate 1.2). A low citrate dose (2.5–3 mmol/l) and a higher than usual target circuit-Ca²⁺ (≤0.5 mmol/l) have been adopted.

Results

Two historical groups of heart surgery patients (n = 40) underwent RCA-CRRT with protocol A (n = 20, 102 circuits, total running time 5283 hours) or protocol B (n = 20, 138 circuits, total running time 7308 hours). Despite higher circuit-Ca²⁺ in protocol B (0.37 vs 0.42 mmol/l, p < 0.001), circuit life was comparable (51.8 ± 36.5 vs 53 ± 32.6 hours). Protocol A required additional bicarbonate supplementation (6 ± 6.4 mmol/h) in 90% of patients while protocol B ensured appropriate acid–base balance without additional interventions: pH 7.43 (7.40–7.46), Bicarbonate 25.3 (23.8–26.6) mmol/l, BE 0.9 (-0.8 to +2.4); median (IQR). No episodes of clinically relevant metabolic alkalosis, requiring modifications of RCA-CRRT settings, were observed. Phosphate supplementation was needed in all group A patients (3.4 ± 2.4 g/day) and in only 30% of group B patients (0.5 ± 1.5 g/day). Hypophosphatemia developed in 75% and 30% of group A and group B patients, respectively. Serum phosphate was significantly higher in protocol B patients (P < 0.001) and, differently to protocol A, appeared to be steadily maintained in near normal range (0.97–1.45 mmol/l, IQR).

Conclusions

The proposed RCA-CVVHDF protocol ensured appropriate acid–base balance without additional interventions, providing prolonged filter life despite adoption of a higher target circuit-Ca²⁺. The introduction of a phosphate-containing solution, in the setting of RCA, significantly reduced CRRT-related phosphate depletion.

【 授权许可】

   
2013 Morabito et al.; licensee BioMed Central Ltd.

【 图 表 】

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