Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation – An observational case-control stud

Background: Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation. Methods: This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors. Results: Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors. Conclusions: The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

Biochemical elucidation of citrate accumulation in Synechocystis sp. PCC 6803 via kinetic analysis of aconitase

A unicellular cyanobacterium Synechocystis sp. PCC 6803 possesses a unique tricarboxylic acid (TCA) cycle, wherein the intracellular citrate levels are approximately 1.5–10 times higher than the levels of other TCA cycle metabolite. Aconitase catalyses the reversible isomerisation of citrate and isocitrate. Herein, we biochemically analysed Synechocystis sp. PCC 6803 aconitase (SyAcnB), using citrate and isocitrate as the substrates. We observed that the activity of SyAcnB for citrate was highest at pH 7.7 and 45 °C and for isocitrate at pH 8.0 and 53 °C. The Km value of SyAcnB for citrate was higher than that for isocitrate under the same conditions. The Km value of SyAcnB for isocitrate was 3.6-fold higher than the reported Km values of isocitrate dehydrogenase for isocitrate. Therefore, we suggest that citrate accumulation depends on the enzyme kinetics of SyAcnB, and 2-oxoglutarate production depends on the chemical equilibrium in this cyanobacterium.

Mechanisms underlying neonate specific metabolic effects of volatile anesthetics

Volatile anesthetics (VAs) are widely used in medicine, but the mechanisms underlying their effects remain ill-defined. Though routine anesthesia is safe in healthy individuals, instances of sensitivity are well-documented, and there has been significant concern regarding the impact of VAs on neonatal brain development. Evidence indicates that VAs have multiple targets, with anesthetic and non-anesthetic effects mediated by neuroreceptors, ion channels, and the mitochondrial electron transport chain. Here, we characterize an unexpected metabolic effect of VAs in neonatal mice. Neonatal blood β-hydroxybutarate (β-HB) is rapidly depleted by VAs at concentrations well below those necessary for anesthesia. β-HB in adults, including animals in dietary ketosis, is unaffected. Depletion of β-HB is mediated by citrate accumulation, malonyl-CoA production by acetyl-CoA carboxylase, and inhibition of fatty acid oxidation. Adults show similar significant changes to citrate and malonyl-CoA, but are insensitive to malonyl-CoA, displaying reduced metabolic flexibility compared to younger animals.

The Role of Metabolic Engineering Technologies for the Production of Fatty Acids in Yeast

Metabolic engineering is a cutting-edge field that aims to produce simple, readily available, and inexpensive biomolecules by applying different genetic engineering and molecular biology techniques. Fatty acids (FAs) play an important role in determining the physicochemical properties of membrane lipids and are precursors of biofuels. Microbial production of FAs and FA-derived biofuels has several advantages in terms of sustainability and cost. Conventional yeast Saccharomyces cerevisiae is one of the models used for FA synthesis. Several genetic manipulations have been performed to enhance the citrate accumulation and its conversation into acetyl-CoA, a precursor for FA synthesis. Success has been achieved in producing different chemicals, including FAs and their derivatives, through metabolic engineering. However, several hurdles such as slow growth rate, low oleaginicity, and cytotoxicity are still need to be resolved. More robust research needs to be conducted on developing microbes capable of resisting diverse environments, chemicals, and cost-effective feed requirements. Redesigning microbes to produce FAs with cutting-edge synthetic biology and CRISPR techniques can solve these problems. Here, we reviewed the technological progression of metabolic engineering techniques and genetic studies conducted on S. cerevisiae, making it suitable as a model organism and a great candidate for the production of biomolecules, especially FAs.

Regional citrate anticoagulation versus low molecular weight heparin for CRRT in hyperlactatemia patients: A retrospective case-control study

Introduction: There were controversial opinions on the use of regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) for continuous renal replacement therapy (CRRT) in hyperlactatemia patients, which was considered as one of the contraindications of citrate. The aim of our present study is to evaluate the efficacy and safety of RCA versus LMWH for CRRT in hyperlactatemia patients. Methods: Adult patients with hyperlactatemia who underwent RCA or LMWH CRRT in our center between January 2014 and March 2018 were retrospectively recruited. Filter lifespan, ultrafiltration, purification, bleeding, citrate accumulation, filter clot, and the infusion of blood production were evaluated as endpoints. Results: Of the 127 patients included in the original cohort, 81 and 46 accepted RCA and LMWH CRRT, respectively. The filter lifespan was significantly prolonged in the RCA group compared to the LMWH group (44.25 h [2 -83] vs. 24 h [4 -67], p < 0.001). The accumulated filter survival proportions were significantly improved in the RCA group compared to the LMWH group in the original cohort ( p < 0.001) as well as the matched group ( p < 0.001). The filters clotted more frequently in the LMWH group than in the RCA group in both of the original (52.2% vs 26.8%, p = 0.001) and matched cohort (58.6% vs 19.4%, p = 0.001). The bleeding complication was significantly reduced in the RCA group than in the LMWH group in the matched cohort (28.6% vs 4.5%, p = 0.04). Conclusion: In critically ill patients with hyperlactatemia requiring CRRT, RCA is superior to LMWH in terms of filter lifespan and bleeding risk without significantly increased risk of citrate accumulation and citrate related metabolic complications. RCA most likely is a safe and effective anticoagulation method for CRRT in patients with hyperlactatemia.

Analysis of the extracorporeal anticoagulation effect of modified citrate infusion during continuous haemodialysis in critically ill patients

This study aimed to analyse the anticoagulation effect of different local infusion methods for citrate continuous haemodialysis in critically ill patients in order to identify a safe and effective citrate infusion method. Critically ill patients admitted to our hospital from April 2019 to December 2019 who underwent continuous renal replacement therapy (CRRT) using citrate for anticoagulation were divided into the conventional citrate infusion before the filter (conventional group) and citrate infusion group according to the different local citrate infusion methods (modified group). A total of 30 treatment sessions were performed for each group. the modified group patients were found to have longer mean treatment times(67.67 ± 18.69 vs 52.11 ± 24.26,p = 0.007), lower transmembrane pressures at the disconnection time from dialysis circuit(147.77 ± 66.85 vs 200.63 ± 118.66,p = 0.038), fewer citrate bag replacements(1.43 ± 0.50 vs 10.60 ± 3.19,p < 0.001), and steady ionised calcium at the venous end compared to the conventional group patients with statistically significant differences(0.35 ± 0.06 vs 0.40 ± 0.05,p = 0.006). The total calcium level was significantly higher in the conventional group patients than those of the other(2.29 ± 0.23 vs 2.19 ± 0.14,p = 0.038). Incidences of citrate accumulation and tubing coagulation were also marginally lower in the modified group. We infer that the modified local citrate infusion method can prolong the treatment time, reduce the nursing workload and the occurrence of citrate accumulation, resulting in safe and effective clinical outcome.

Mechanisms underlying neonate specific metabolic effects of volatile anesthetics

Volatile anesthetics (VAs) are widely used in medicine, but the mechanisms underlying their effects remain ill-defined. Though routine anesthesia is safe in healthy individuals, instances of sensitivity are well-documented, and there has been significant concern regarding the impact of VAs on neonatal brain development. Evidence indicates that VAs have multiple targets, with anesthetic and non-anesthetic effects mediated by neuroreceptors, ion channels, and the mitochondrial electron transport chain. Here, we characterize an unexpected metabolic effect of VAs in neonatal mice. Neonatal blood β-hydroxybutarate (ß-HB) is rapidly depleted by VAs at concentrations well below those necessary for anesthesia. β-HB in adults, including animals in dietary ketosis, is unaffected. Depletion of β-HB is mediated by citrate accumulation, malonyl-CoA production by acetyl-CoA carboxylase, and inhibition of fatty acid oxidation. Adults show similar significant changes to citrate and malonyl-CoA, but are insensitive to malonyl-CoA, displaying reduced metabolic flexibility compared to younger animals.