Energy expenditure and caloric targets during continuous renal replacement therapy under regional citrate anticoagulation. A viewpoint.

BACKGROUND

Indirect calorimetry (IC) is the gold standard for measuring energy expenditure in critically ill patients However, continuous renal replacement therapy (CRRT) is a formal contraindication for IC use.

AIMS

To discuss specific issues that hamper or preclude an IC-based assessment of energy expenditure and correct caloric prescription in CRRT-treated patients.

METHODS

Narrative review of current literature.

RESULTS

Several relevant pitfalls for validation of IC during CRRT were identified. First, IC measures CO production (VCO) and O consumption to calculate resting energy expenditure (REE) with the Weir equation. VCO measurements are influenced by CRRT because CO is exchanged during the blood purification process. CO exchange also depends on type of pre- and/or postdilution fluid(s). CO dissolves in different forms with dynamic but unpredictable impact on VCO. Second, the effect of immunologic activation and heat loss on REE caused by extracorporeal circulation during CRRT is poorly documented. Third, caloric prescription should be adapted to CRRT-induced in- and efflux of different nutrients. Finally, citrate, which is the preferred anticoagulant for CRRT, is a caloric source that may influence IC measurements and REE.

CONCLUSION

Better understanding of CRRT-related processes is needed to assess REE and provide individualized nutritional therapy in this condition.