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Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D
Willem Boer1, Tom Fivez2, Margot Vander Laenen2
1Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium. wllm.br@gmail.com.
Insights
Higher citrate doses in continuous venovenous hemofiltration (CVVH) increase calcium and magnesium loss, but physician-guided supplementation maintains balance. Parathormone levels decreased, indicating reduced oxidative stress, while Vitamin D levels changed without significant group differences.
Area of Science:
- Nephrology and Critical Care Medicine
- Renal Replacement Therapy
- Biochemistry and Mineral Metabolism
Background:
- Regional citrate anticoagulation in continuous venovenous hemofiltration (CVVH) may lead to negative calcium balance and hypocalcemia.
- Systemic hypocalcemia can activate parathormone (PTH), but randomized studies are lacking.
- The impact of varying citrate doses on calcium and magnesium balance, PTH, and Vitamin D requires investigation.
Purpose of the Study:
- To determine the effect of different citrate doses on calcium (Ca) and magnesium (Mg) balance during CVVH.
- To assess the impact of citrate dose on parathormone (PTH) and Vitamin D levels.
- To evaluate the efficacy of physician-ordered supplementation in maintaining mineral balance.
Main Methods:
- A single-center prospective randomized study involving 35 patients undergoing CVVH with citrate.
- Patients were randomized to low-dose (2.5 mmol/L) or high-dose (4.5 mmol/L) citrate for 24 hours.
- Ionized calcium targets, physician-ordered supplementation, and blood/effluent sampling for mineral and hormone analysis were employed.
Main Results:
- The high citrate dose group exhibited a significantly more negative 24-hour calcium balance (-9.72 mmol/d) compared to the low citrate group (-1.18 mmol/d).
- Magnesium balance was also more negative in the high citrate group (-25.99 mmol/d) versus the low citrate group (-17.63 mmol/d).
- Despite negative balances, physician-ordered calcium supplementation resulted in positive calcium balance in both groups; PTH levels decreased, and Vitamin D levels showed changes without intergroup differences.
Conclusions:
- Higher citrate doses in CVVH lead to greater calcium and magnesium losses via effluent.
- Physician-ordered calcium supplementation effectively corrects negative calcium balance, irrespective of citrate dose.
- Declines in intact and oxidized PTH suggest reduced oxidative stress, while 25-hydroxyvitamin D decreased and 1,25-dihydroxyvitamin D increased.
Background:
Regional citrate anticoagulation may cause a negative calcium balance, systemic hypocalcemia and parathormone (PTH) activation but randomzed studies are not available. Aim was to determine the effect of citrate dose on calcium (Ca) and magnesium (Mg) balance, PTH and Vitamin D.
Methods:
Single center prospective randomized study. Patients, requiring continuous venovenous hemofiltration (CVVH) with citrate, randomized to low dose citrate (2.5 mmol/L) vs. high dose (4.5 mmol/L) for 24 h, targeting post-filter ionized calcium (pfiCa) of 0.325-0.4 mmol/L vs. 0.2-0.275 mmol/L, using the Prismaflex® algorithm with 100% postfilter calcium replacement. Extra physician-ordered Ca and Mg supplementation was performed aiming at systemic iCa > 1.0 mmol/L. Arterial blood, effluent and post-filter aliquots were taken for balance calculations (area under the curve), intact (i), oxidized (ox) and non-oxidized (nox) PTH, 25-hydroxy-Vitamin D (25D) and 1,25-dihydroxy-Vitamin D (1,25D).
Results:
35 patients were analyzed, 17 to high, 18 to low citrate. Mean 24-h Ca balance was - 9.72 mmol/d (standard error 1.70) in the high vs - 1.18 mmol/d (se 1.70)) (p = 0.002) in the low citrate group and 24-h Mg-balance was - 25.99 (se 2.10) mmol/d vs. -17.63 (se 2.10) mmol/d (p = 0.008) respectively. Physician-ordered Ca supplementation, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH, oxPTH or noxPTH were not different between groups. Over 24 h, median PTH decreased from 222 (25th-75th percentile 140-384) to 162 (111-265) pg/ml (p = 0.002); oxPTH from 192 (124-353) to 154 pg/ml (87-231), p = 0.002. NoxPTH did not change significantly. Mean 25 D (standard deviation), decreased from 36.5 (11.8) to 33.3 (11.2) nmol/l (p = 0.003), 1,25D rose from 40.9 pg/ml (30.7) to 43.2 (30.7) pg/ml (p = 0.046), without differences between groups.
Conclusions:
A higher citrate dose caused a more negative CVVH Ca balance than a lower dose, due to a higher effluent Calcium loss. Physician-ordered Ca supplementation, targeting a systemic iCa > 1.0 mmol/L, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH and oxPTH declined, suggesting decreased oxidative stress, while noxPTH did not change. 25D decreased while 1,25-D rose. Mg balance was negative in both groups, more so in the high citrate group.
Trial Registration:
ClinicalTrials.gov : NCT02194569. Registered 18 July 2014.
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