Clinical and biological profiles associated with the time of occurrence of citrate accumulation in patients receiving continuous renal replacement therapy

IF 9.3 1区医学 Q1 CRITICAL CARE MEDICINE

Critical Care Pub Date : 2025-09-26 DOI:10.1186/s13054-025-05648-5

Frank Bidar, Nicolas Chardon, Quentin Darnajoux, Matthieu Petit, Jean-Luc Fellahi, Frederic Aubrun, Laurent Argaud, Jean-Christophe Richard, Frederic Dailler, Florent Wallet, Thomas Rimmelé

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Abstract

Citrate accumulation (CA) is a feared complication in critically ill patients undergoing regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT). This study aimed to describe the characteristics of patients presenting CA within a large cohort of unselected critically ill patients receiving RCA-CRRT depending on the time of occurrence of CA after CRRT initiation. This retrospective, multicenter observational study performed in nine intensive care units (ICU) in Lyon, France, included patients treated with RCA-CRRT between January 2020 and January 2022. CA was defined by a total to ionized calcium ratio (tCa/iCa) ≥ 2.3 associated with hypocalcemia and metabolic acidosis. Among 2080 patients, 76 (3.7%) developed CA: 69 (91%) experienced CA within 24 h after CRRT initiation (initial CA) and 7 (9%) after 24 h (late-onset CA). Only lactate levels at CRRT initiation differed between patients with initial CA and those with late-onset CA (10 mmol/l [4.6–16] vs 1.4 mmol/l [1–3.8], p = 0.006 respectively). In the initial CA group, 39 (57%) exhibited signs of CA within 6 h or less (immediate CA) and 30 (43%) showed signs of CA between 6 and 24 h. Over the first 24 h, patients with initial CA presented a marked increase in lactate levels, worsening norepinephrine requirements, persistent elevation of the tCa/iCa ratio, decrease in prothrombin time, and increase in transaminases. Patients with immediate CA showed higher lactate concentration and more severe metabolic acidosis at CRRT initiation compared to patients with early CA whereas other markers did not differ significantly between the two groups. The area under the Receiver Operating Characteristic curve of lactate and pH for predicting immediate citrate accumulation were 0.75 [0.62 – 0.87] and 0.74 [0.62 – 0.85] respectively, with optimal cutoff values of 10.6 mmol/L and 7.14 respectively. The ICU mortality rate among patients with CA was 97% compared to 55% in the whole cohort. CA is a rare phenomenon in patients under RCA-CRRT. Severe metabolic acidosis with hyperlactatemia at CRRT initiation is the most relevant marker to identify patients at risk of immediate CA and should encourage close monitoring of tCa/iCa ratio.

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临床和生物学特征与接受持续肾替代治疗的患者发生柠檬酸盐积累的时间相关

柠檬酸盐蓄积（CA）是危重患者接受局部柠檬酸抗凝（RCA）持续肾替代治疗（CRRT）时令人担忧的并发症。本研究旨在描述在接受RCA-CRRT的大量未选择的危重患者中，根据CRRT开始后CA发生的时间，出现CA的患者的特征。这项回顾性、多中心观察性研究在法国里昂的9个重症监护病房（ICU）进行，纳入了2020年1月至2022年1月期间接受RCA-CRRT治疗的患者。CA定义为总钙离子比(tCa/iCa)≥2.3，伴有低钙血症和代谢性酸中毒。2080例患者中，76例（3.7%）发生CA， 69例（91%）在CRRT开始后24小时内发生CA（初始CA）， 7例（9%）在24小时后发生CA（晚发型CA）。只有初始CA患者和迟发性CA患者在CRRT启动时的乳酸水平不同（10 mmol/l [4.6-16] vs 1.4 mmol/l [1-3.8], p = 0.006）。在初始CA组中，39例（57%）在6小时或更短时间内表现出CA的迹象（立即CA）， 30例（43%）在6至24小时之间表现出CA的迹象。在最初的24小时内，初始CA患者表现出乳酸水平明显升高，去甲肾上腺素需求恶化，tCa/iCa比率持续升高，凝血酶原时间减少，转氨酶增加。与早期CA患者相比，即刻CA患者在CRRT开始时表现出更高的乳酸浓度和更严重的代谢性酸中毒，而其他标志物在两组之间没有显着差异。乳酸盐和pH值的受体工作特性曲线下面积分别为0.75[0.62 ~ 0.87]和0.74[0.62 ~ 0.85]，最佳临界值分别为10.6 mmol/L和7.14。CA患者的ICU死亡率为97%，而整个队列的死亡率为55%。CA在RCA-CRRT患者中是一种罕见的现象。CRRT开始时伴有高乳酸血症的严重代谢性酸中毒是识别立即CA风险患者的最相关标志，应鼓励密切监测tCa/iCa比率。

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来源期刊

Critical Care 医学-危重病医学

CiteScore

20.60

自引率

3.30%

发文量

348

审稿时长

1.5 months

期刊介绍： Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.