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Clinical Trial
. 2020 Dec;39(12):3797-3803.
doi: 10.1016/j.clnu.2020.04.017. Epub 2020 Apr 21.

MECCIAS trial: Metabolic consequences of continuous veno-venous hemofiltration on indirect calorimetry

J Jonckheer  1 , J Demol  2 , K Lanckmans  3 , M L N G Malbrain  4 , H Spapen  4 , E De Waele  5
Affiliations
Free article
Clinical Trial

MECCIAS trial: Metabolic consequences of continuous veno-venous hemofiltration on indirect calorimetry

J Jonckheer et al. Clin Nutr. 2020 Dec.
Free article

Abstract

Background: and aims: Caloric prescription based on resting energy expenditure (REE) measured with indirect calorimetry (IC) improves outcome and is the gold standard in nutritional therapy of critically ill patients. Until now continuous renal replacement therapy (CRRT) precluded the use of IC due to several mechanisms. We investigated the impact of CRRT on V̇CO2, V̇O2 and REE to facilitate indirect calorimetry during CRRT.

Methods: In 10 critically ill ventilated patient in need of continuous veno-venous hemofiltration (CVVH) using citrate predilution we performed IC in 4 different states: baseline, high dose, baseline with NaCl predilution and without CVVH. CO2 content of effluent fluid was measured by a point of care blood gas analyzer. Carbon dioxide production (V̇CO2) measured with IC was adapted by adding the CO2 flow of effluent and deducing CO2 flow in postdilution fluid to calculate a true V̇CO2. True REE was calculated with the Weir equation using the true V̇CO2.

Results: CO2 removal in effluent during baseline, high dose and NaCl predilution was respectively 24 mL/min, 38 mL/min and 23 mL/min. Together with the CO2 delivery by the postdilution fluid this led to an adaptation of REE respectively by 34 kcal/d or 2% (p = 0,002), 44 kcal/d or 3% (p = 0,002) and 33 kcal/d or 2% (p = 0,002). Compared to the true REE during baseline of 1935 ± 921 kcal/d, true REE during high dose was 1723 ± 752 kcal/d (p = 0.65), during NaCl predilution it was 1604 ± 633 kcal/d (p = 0.014) and without CRRT it was 1713 ± 704 kcal/d (p = 0.193).

Conclusions: CO2 alterations due to CVVH are clinically of no importance so no correction factor of REE is needed with or without CVVH. IC must be performed during CVVH as CVVH seems to alter metabolism. These changes may be mainly explained by the use of citrate predilution.

Keywords: Citrate; Continuous renal replacement therapy; Continuous veno-venous hemofiltration; Indirect calorimetry; Metabolism; Resting energy expenditure.

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Conflict of interest statement

Conflicts of interest Dr. Manu Malbrain, Phd, is professor at the faculty of Medicine and Pharmacy at the Vrije Universiteit Brussels (VUB) and member of the Executive Committee of the Abdominal Compartment Society, formerly known as the World Society of Abdominal Compartment Syndrome (https://www.wsacs.org/). He is former president, co-founder and current Treasurer of WSACS. He is also co-founder of the International Fluid Academy (IFA). The IFA is integrated within the not-for-profit charitable organization iMERiT, International Medical Education and Research Initiative, under Belgian law. The content of the IFA website (http://www.fluidacademy.org) is based on the philosophy of FOAM (Free Open Access Medical education – #FOAMed). He is a member of the medical advisory Board of Pulsion Medical Systems (now fully integrated in Getinge, Solna, Sweden) and Serenno Medical (Tel Aviv, Israel), he consults for Baxter, Maltron, ConvaTec, Acelity, Spiegelberg and Holtech Medical. Prof. de Waele reported having received grant funding from the Belgian Government of Health and grant funding and honoraria for advisory board meetings, lectures, and travel expenses from Baxter Healthcare, Fresenius Kabi BBraun, Cardinal Health and Danone-Nutricia. The other authors have nothing to disclose.

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