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Open Access 07-11-2022 | Hemofiltration | Original Article

Negative calcium balance despite normal plasma ionized calcium concentrations during citrate anticoagulated continuous venovenous hemofiltration (CVVH) in ICU patients

Authors: Evert de Jonge, Marije van der Vooren, Judith M. E. P. Gillis, Michael R. del Prado, Jeanette Wigbers, Ferishta Bakhshi-Raiez, Carlos V. Elzo Kraemer

Published in: Journal of Nephrology | Issue 4/2023

Abstract

Background

Supplementation of calcium during continuous venovenous hemofiltration (CVVH) with citrate anticoagulation is usually titrated using a target blood ionized calcium concentration. Plasma calcium concentrations may be normal despite substantial calcium loss, by mobilization of calcium from the skeleton. Aim of our study is to develop an equation to calculate CVVH calcium and to retrospectively calculate CVVH calcium balance in a cohort of ICU-patients.

Methods

This is a single-center retrospective observational cohort study. In a subcohort of patients, all calcium excretion measurements in patients treated with citrate CVVH were randomly divided into a development set (n = 324 in 42 patients) and a validation set (n = 441 in 42 different patients). Using mixed linear models, we developed an equation to calculate calcium excretion from routinely available parameters. We retrospectively calculated calcium balance in 788 patients treated with citrate CVVH between 2014 and 2021.

Results

Calcium excretion (mmol/24 h) was − 1.2877 + 0.646*[Ca]_blood,total * ultrafiltrate (l/24 h) + 0.107*blood flow (ml/h). The mean error of the estimation was − 1.0 ± 6.7 mmol/24 h, the mean absolute error was 4.8 ± 4.8 mmol/24 h. Calculated calcium excretion was 105.8 ± 19.3 mmol/24 h. Mean daily CVVH calcium balance was − 12.0 ± 20.0 mmol/24 h. Mean cumulative calcium balance ranged from − 3687 to 448 mmol.

Conclusion

During citrate CVVH, calcium balance was negative in most patients, despite supplementation of calcium based on plasma ionized calcium levels. This may contribute to demineralization of the skeleton. We propose that calcium supplementation should be based on both plasma ionized calcium and a simple calculation of calcium excretion by CVVH.

Graphical abstract

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Title: Negative calcium balance despite normal plasma ionized calcium concentrations during citrate anticoagulated continuous venovenous hemofiltration (CVVH) in ICU patients
Authors: Evert de Jonge
Marije van der Vooren
Judith M. E. P. Gillis
Michael R. del Prado
Jeanette Wigbers
Ferishta Bakhshi-Raiez
Carlos V. Elzo Kraemer
Publication date: 07-11-2022
Publisher: Springer International Publishing
Keyword: Hemofiltration
Published in: Journal of Nephrology / Issue 4/2023
Print ISSN: 1121-8428
Electronic ISSN: 1724-6059
DOI: https://doi.org/10.1007/s40620-022-01482-y

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