Autori: Zeppilli L (1), Pistolesi V (1), Di Mario F (1), Santoboni F (1), Fiaccadori E (2), Morabito S (1)
Affiliazioni: (1) UOD Dialisi, Policlinico Umberto I, Sapienza, Università di Roma; (2) Unità Fisiopatologia dell’Insufficienza Renale, Università degli Studi di Parma
Introduction: RCA is increasingly used in the critically ill to minimize CRRT-related bleeding risk. Citrate metabolism is O2-dependent and any cause of intracellular hypoxemia could lead to citrate accumulation (CA), especially in presence of severe hyperlactatemia. Aim: to describe our experience with a RCA-CVVHDF protocol safely performed in critically ill patients with baseline hyperlactatemia (HLac)(Lac>2.2mmol/l). Methods: In cardiac surgery pts with severe acute kidney injury (CS-AKI) and HLac, but stable or downward Lac trend, we started CRRT adopting an RCA protocol characterized by a low citrate metabolic load in CVVHDF modality. A pre-dilution citrate solution (18mmol/l), combined with a phosphate-containing solution acting as dialysate and post-dilution replacement fluid, was used. Results: In 4 pts (age 72.2±12.5, CV-SOFA score 3±0.8, Lac 4.8±1.9 mmol/l) RCA-CVVHDF was performed for at least 48h (43 circuits, filter life 45.6±25.4h, total running time 1962h). CRRT initial parameters: prescribed dose 27.3±2.7 ml/Kg/h; citrate dose 2.9±0.1 mmol/l; citrate load 11.9±0.2 mmol/h. A reduction of Lac was observed over CRRT treatment (1.5±0.5 mmol/l at 24h). No pts had signs of CA: calcium ratio was steadily below the threshold of 2.5 over the course of CRRT; systemic ionized calcium was easily maintained within normal range with no needs to increase CaCl2infusion rate (2.2±0.4 mmol/h); no occurrence of worsening metabolic acidosis was observed. Discussion: Provided that an RCA setting aimed at appropriately reducing citrate load is adopted, citrate may be safely used even in pts with hyperlactatemia, at least in those with stable or downward lactate trend.