CaCl2-Citrate Regional Anticoagulation with Continuous Veno-Venous Haemodialysis Leads to Unwanted Chloride Loading Compared to Continuous Veno-Venous Hemofiltration with Systemic Anticoagulation.

IF 2.2 3区医学 Q3 HEMATOLOGY Blood Purification Pub Date : 2024-08-30 DOI:10.1159/000541059

Matthieu Chivot, Ian Baldwin, Guillaume Deniel, Guillaume David, Glenn M Eastwood, Jean-Christophe Richard, Rinaldo Bellomo, Laurent Bitker

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Abstract

Introduction: Chloride transfers during continuous renal replacement therapy (CRRT) have not been adequately described and may differ based on CRRT technique. We aimed to measure chloride mass transfer (JS,Cl) during CRRT and identify associated determinants.

Methods: We performed a two-centre, prospective, observational study in France and Australia in ICU patients with CRRT initiated for <24 h. Patients received continuous veno-venous hemofiltration (CVVH) or continuous veno-venous haemodialysis (CVVHD, with citrate-CaCl2 regional anticoagulation). Over a 24 h period, plasma and effluent chloride concentrations were measured every 4 h to compute chloride mass transfer (JS,Cl, in mmol.min-1) using a modality-specific model, with negative value indicating chloride transfer towards the patient. Secondary outcomes were the identification of CRRT settings associated with JS,Cl (using multivariate mixed effects regression). Results are presented with median (interquartile range).

Results: Between February 2021 and August 2022, we enrolled 37 patients (64 [56-71] years, 67% male), for a total of 20 CVVHD and 20 CVVH sessions. Over 24 h, plasma chloride concentrations were significantly higher, and JS,Cl significantly lower during CVVHD, compared to CVVH (-0.10 [-0.33 to 0.15] vs. 0.01 [-0.10 to 0.13] mmol.min-1, p < 0.05). With both modalities, net ultrafiltration (QUFNET) and plasma chloride concentrations were the principal determinants of JS,Cl, with higher QUFNET being associated with an increase in JS,Cl during CVVHD. Also, CVVHD sessions demonstrated a concentration gradient between the plasma and the effluent chamber of -6 [-9 to -4] mmol.L-1. Finally, CaCl2 reinjection during CVVHD accounted for 35% [32-60%] of total JS,Cl in sessions with a negative JS,Cl.

Conclusion: Compared to CVVH, CVVHD with regional citrate anticoagulation was associated with greater chloride mass transfer to the patient and higher plasma chloride concentrations. This was due to high dialysate chloride concentrations and CaCl2 reinjection. This effect could only be controlled by high net ultrafiltration flow rates.

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与全身抗凝的 CVVHD 相比，CaCl2-柠檬酸区域抗凝会导致不必要的氯离子负荷。

简介：连续性肾脏替代疗法（CRRT）期间的氯化物转移尚未得到充分描述，并且可能因 CRRT 技术而异。我们旨在测量 CRRT 期间的氯化物质量转移（JS,Cl），并确定相关的决定因素：我们在法国和澳大利亚的两个中心开展了一项前瞻性观察研究，研究对象是启动 CRRT 24 小时的 ICU 患者。患者接受连续静脉-静脉血液滤过（CVVH）或连续静脉-静脉血液透析（CVVHD，枸橼酸盐-氯化钙区域抗凝）。在 24 小时内，每隔 4 小时测量一次血浆和流出液中的氯化物浓度，以使用特定模式计算氯化物的质量转移（JS,Cl，单位：mmol.min-1），负值表示氯化物向患者转移。次要结果是确定与 JS,Cl 相关的 CRRT 设置（使用多变量混合效应回归）。结果以中位数[四分位数间距]表示：2021 年 2 月至 2022 年 8 月期间，我们招募了 37 名患者（64 [56-71] 岁，67% 为男性），共进行了 20 次 CVVHD 和 20 次 CVVH 治疗。24 小时内，与 CVVH 相比，CVVHD 期间血浆氯化物浓度明显更高，JS,Cl 明显更低（-0.10 [-0.33-0.15] vs. 0.01 [-0.10-0.13] mmol.min-1，P<0.05）。在两种模式下，净超滤（QUFNET）和血浆氯化物浓度是 JS,Cl 的主要决定因素，在 CVVHD 期间，QUFNET 越高，JS,Cl 越高。此外，CVVHD 会话显示血浆和流出室之间的浓度梯度为 -6 [-9- -4] mmol.L-1。最后，在 JS,Cl 为负值的疗程中，CVVHD 期间的 CaCl2 再注射占总 JS,Cl 的 35% [32%-60%] ：结论：与 CVVHD 相比，CVVHD 加上区域性枸橼酸盐抗凝会导致更多的氯化物转移到患者体内，血浆氯化物浓度也更高。这是由于透析液氯化物浓度高和 CaCl2 再注射造成的。这种影响只能通过高净超滤流速来控制。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Blood Purification 医学-泌尿学与肾脏学

CiteScore

5.80

自引率

3.30%

发文量

审稿时长

6-12 weeks

期刊介绍： Practical information on hemodialysis, hemofiltration, peritoneal dialysis and apheresis is featured in this journal. Recognizing the critical importance of equipment and procedures, particular emphasis has been placed on reports, drawn from a wide range of fields, describing technical advances and improvements in methodology. Papers reflect the search for cost-effective solutions which increase not only patient survival but also patient comfort and disease improvement through prevention or correction of undesirable effects. Advances in vascular access and blood anticoagulation, problems associated with exposure of blood to foreign surfaces and acute-care nephrology, including continuous therapies, also receive attention. Nephrologists, internists, intensivists and hospital staff involved in dialysis, apheresis and immunoadsorption for acute and chronic solid organ failure will find this journal useful and informative. ''Blood Purification'' also serves as a platform for multidisciplinary experiences involving nephrologists, cardiologists and critical care physicians in order to expand the level of interaction between different disciplines and specialities.