Effect of continuous dialysis on blood pH in acidemic hypercapnic animals with severe acute kidney injury: a randomized experimental study comparing high vs. low bicarbonate affluent

Abstract

Background: Controlling blood pH during acute ventilatory failure and hypercapnia in individuals suffering from severe acute kidney injury (AKI) and undergoing continuous renal replacement therapy (CRRT) is of paramount importance in critical care settings. In this situation, the optimal concentration of sodium bicarbonate in the dialysate is still an unsolved question in critical care since high concentrations may worsen carbon dioxide levels and low concentrations may not be as effective in controlling pH. Methods: We performed a randomized, non-blinded, experimental study. AKI was induced in 12 female pigs via renal hilum ligation and hypoventilation by reducing the tidal volume during mechanical ventilation with the goal of achieving a pH between 7.10-7.15. After achieving the target pH, animals were randomized to undergo isovolemic hemodialysis with one of two bicarbonate concentrations in the dialysate (40 mEq/L [group 40] vs. 20 mEq/L [group 20]). Results: Hemodynamic, respiratory, and laboratory data were collected. The median pH value at CRRT initiation was 7.14 [7.12, 7.15] in group 20 and 7.13 [7.09, 7.14] in group 40 (P = ns). The median baseline PaCO2 was 74 [72, 81] mmHg in group 20 vs. 79 [63, 85] mmHg in group 40 (P = ns). After 3 h of CRRT, the pH value was 7.05 [6.95, 7.09] in group 20 and 7.12 [7.1, 7.14] in group 40 (P < 0.05), with corresponding values of PaCO2 of 85 [79, 88] mmHg vs. 81 [63, 100] mmHg (P = ns). The difference in pH after 3 h was due to a metabolic component [standard base excess -10.4 [-12.5, -9.5] mEq/L in group 20 vs. -7.6 [-9.2, -5.1] mEq/L in group 40) (P < 0.05)]. Despite the increased infusion of bicarbonate in group 40, the blood CO2 content did not change during the experiment. The 12-h survival rate was higher in group 40 (67% vs. 0, P = 0.032). Conclusions: A higher bicarbonate concentration in the dialysate of animals undergoing hypercapnic respiratory failure was associated with improved blood pH control without increasing the PaCO2 levels.