%0 Journal Article
%T Hyperlactatemia Predicts Citrate Intolerance With Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy
%A Amartya Mukhopadhyay
%A Horng-Ruey Chua
%A Jason Phua
%A Jia-Neng Tan
%A Nicholas Lee
%A Sabrina Wong Peixin Haroon
%A Tanusya M. Murali
%A Titus Lau
%A Zong-Yao Tan
%J Journal of Intensive Care Medicine
%@ 1525-1489
%D 2019
%R 10.1177/0885066617701068
%X 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 ¡À 14 years, 66% males, Acute Physiology and Chronic Health Evaluation II: 31 ¡À 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 ¡Ü4 mmol/L (P ¡Ü .001), despite comparable citrate load and effluent rates across all categories. On multivariate analysis, hyperlactatemia and hyperbilirubinemia predicted CI (P ¡Ü .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
%K acute kidney injury
%K continuous renal replacement therapy
%K hemodialysis
%K hyperlactatemia
%K citrate toxicity and intolerance
%K critical care
%K intensive care unit
%K lactate and shock
%K regional citrate anticoagulation
%U https://journals.sagepub.com/doi/full/10.1177/0885066617701068