1 Division of Nephrology, University Medicine Cluster, National University Hospital, Republic of Singapore.
2 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.
J Intensive Care Med. 2019 May;34(5):418-425. doi: 10.1177/0885066617701068. Epub 2017 Apr 4.
: We aim to determine whether hyperlactatemia, which suggests multi-organ dysfunction and impaired organic substrate metabolism, may predict intolerance to regional citrate anticoagulation (RCA) during continuous venovenous hemofiltration (CVVH).
: We performed a single-center, retrospective observational study in critically ill patients with acute kidney injury or end-stage renal disease and evaluated the association of peak serum lactate levels with citrate intolerance (CI) during the initial 72 hours of RCA-CVVH, defined by serum total-to-ionized calcium >2.5 plus systemic hypocalcemia.
: Eighty-eight patients were studied (aged 59 ± 14 years, 66% males, Acute Physiology and Chronic Health Evaluation II: 31 ± 8). Citrate was dosed at median 2.1 mmol/L of blood flow, with citrate load of 30 mmol/h, and CVVH effluent of 43 mL/kg/h. Twenty patients developed CI. Comparing patients with CI versus none, peak lactate levels were 8 (5-11) versus 3 (2-6) mmol/L, calcium replacement was 13 (10-17) versus 11 (8-12) mmol/h, and standard base excess was -4 (-12 to 1) versus 2(-4 to 7) mmol/L, respectively ( P < .05). Citrate intolerance developed in 38%, 44%, and 55%, in patients with peak lactate >4, >6, >7 mmol/L, respectively, versus 7% in those with peak lactate ≤4 mmol/L ( P ≤ .001), despite comparable citrate load and effluent rates across all categories. On multivariate analysis, hyperlactatemia and hyperbilirubinemia predicted CI ( P ≤ .01), which was associated with increasing calcium infusion requirement. Higher peak lactate from >4 to >7 mmol/L predicted CI with graded increase in odds ratio and specificity from 59% to 87%, but the corresponding negative predictive value from 93% to 87%. Area under nonparametric receiver operating characteristic curve for peak lactate and CI was 0.78.
: Hyperlactatemia predicts CI during RCA-CVVH with reasonable discriminatory performance in critically ill patients. Serum lactate surveillance may help preempt issues with citrate toxicity.
我们旨在确定高乳酸血症（提示多器官功能障碍和有机底物代谢受损）是否可预测连续性静脉-静脉血液滤过（CVVH）期间局部枸橼酸盐抗凝（RCA）不耐受。
我们进行了一项单中心、回顾性观察性研究，纳入了急性肾损伤或终末期肾病的危重症患者，并评估了初始 72 小时 RCA-CVVH 期间血清乳酸峰值与枸橼酸盐不耐受（CI）的相关性，CI 的定义为血清总钙与离子钙比值＞2.5 加上全身低钙血症。
共纳入 88 例患者（年龄 59±14 岁，66%为男性，急性生理学和慢性健康评估Ⅱ评分：31±8）。枸橼酸盐的血流中位剂量为 2.1mmol/L，枸橼酸盐负荷为 30mmol/h，CVVH 流出量为 43mL/kg/h。20 例患者发生 CI。与无 CI 相比，CI 组患者的峰值乳酸水平分别为 8（5-11）mmol/L 和 3（2-6）mmol/L，钙补充量分别为 13（10-17）mmol/h 和 11（8-12）mmol/h，标准碱剩余分别为-4（-12 至 1）mmol/L 和 2（-4 至 7）mmol/L（均 P＜0.05）。峰值乳酸＞4mmol/L、＞6mmol/L、＞7mmol/L 的患者中分别有 38%、44%和 55%发生 CI，而峰值乳酸≤4mmol/L 的患者中仅 7%发生 CI（P≤0.001），尽管所有类别中的枸橼酸盐负荷和流出率均相似。多变量分析显示，高乳酸血症和高胆红素血症预测 CI（P≤0.01），这与钙输注需求的增加有关。峰值乳酸从＞4mmol/L 升高至＞7mmol/L 预测 CI 的比值比和特异性逐渐升高，分别从 59%升至 87%，但阴性预测值从 93%降至 87%。峰值乳酸和 CI 的非参数接收者操作特征曲线下面积为 0.78。
在危重症患者中，高乳酸血症可预测 RCA-CVVH 期间的 CI，具有合理的鉴别性能。血清乳酸监测有助于预测枸橼酸盐毒性问题。
