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Bioenergetic Gain of Citrate-Anticoagulated Continuous Renal Replacement Therapy

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Diet and Nutrition in Critical Care

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.

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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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Authors and Affiliations

  1. Department of Anaesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, U nemocnice 2, Prague 2, 120 00, Czech Republic

    M. Balik & M. Zakharchenko

Authors
  1. M. Balik
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  2. M. Zakharchenko
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Correspondence to M. Balik .

Editor information

Editors and Affiliations

  1. Department of Nutrition, King's College London, London, United Kingdom

    Rajkumar Rajendram

  2. School of Medicine, King's College London, London, United Kingdom

    Victor R. Preedy

  3. Department of Biomedical Sciences, University of Westminster, London, United Kingdom

    Vinood B. Patel

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Balik, M., Zakharchenko, M. (2014). Bioenergetic Gain of Citrate-Anticoagulated Continuous Renal Replacement Therapy. In: Rajendram, R., Preedy, V., Patel, V. (eds) Diet and Nutrition in Critical Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8503-2_70-1

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  • DOI: https://doi.org/10.1007/978-1-4614-8503-2_70-1

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  • Online ISBN: 978-1-4614-8503-2

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