Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy ‐ A Safe and Effective Low‐Dose Protocol

Abstract

Aims Regional citrate anticoagulation (RCA) is the preferred mode of anticoagulation for continuous renal replacement therapy (CRRT). Conventional RCA‐CRRT citrate dose ranges from 3 to 5 mmol/L of blood. This study explored the effectiveness of an RCA protocol with lower citrate dose and its impact on citrate‐related complications. Methods This prospective observational study compared two RCA‐CRRT protocols in the intensive care unit. RCA Protocol 1 used an initial citrate dose of 3.0 mmol/L while Protocol 2 started with 2.5 mmol/L. The citrate dose was titrated by sliding scale to target circuit‐iCa 0.26–0.40 mmol/L. Calcium was re‐infused post‐dialyzer and titrated by protocol to target systemic‐iCa 1.01–1.20 mmol/L. Results Two hundred RCA‐CRRT sessions were performed (81 Protocol 1; 119 Protocol 2). The median age was 65.4 years and median APACHE‐II score was 23. Citrate dose for Protocol 1 was significantly higher than Protocol 2 in the first 12 h. The circuit clotting rate was similar in both arms (Protocol 1: 9.9%; Protocol 2: 9.2%; P = 0.881). With Protocol 2, circuit‐iCa levels were 2.42 times more likely to be on target (P = 0.003) while the odds of hypocalcaemia was 4.67 times higher with Protocol 1 (P < 0.001). There was a wider anion gap was noted with Protocol 1, which suggests a propensity for citrate accumulation with higher citrate exposure. Conclusion The RCA protocol with a lower initial citrate dose of 2.5 mmol/L blood had less citrate‐related complications with no loss of efficacy. A more precise RCA prescription at the start of treatment avoids unnecessary citrate exposure and improves safety.

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

“…The low incidence of CA in our study was most likely attributed to the low citrate load (27.2 mmol/h) with sufficient patency of the extracorporeal circuit. 30 Furthermore, we adopted a more rigorous diagnosis criteria of CA than the study by Tan et al 12 Morgera et al 31 reported than more than 50% of patients developed metabolic alkalosis during RCA-CRRT. The rate of metabolic alkalosis in our study was significantly lower because the bicarbonate fluid (B fluid) was infused separately and was adjustable in our protocol.…”

Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic

“…In patients without COVID-19, citrate dose may even be lowered to 2.5 mmol/L, which is noninferior to higher citrate dosing for an optimal filter life in general. 32 In addition, we suggest a balance between RCA and heparinization to allow proportionate consumption of both. Importantly, premature filter clotting is commonly observed in patients with COVID-19.…”

Correcting hyponatremia by fluid sodium modulation in continuous renal replacement therapy with regional citrate anticoagulation

“…However, we did not modify our RCA regimen, and the circuit ioniccalcium was still achieved with up-titration of citrate flow rate according to a sliding scale. 1 This also suggests that the formulae for correction of Na can be used for different citrated-replacement fluid formulations as long as it is titrated according to the circuit calcium Many other factors may influence serum sodium levels, including urine output, intravenous fluids, and medication diluents. To control urine output, IV desmopressin was administered.…”

“…The initial citrate dose was 2.5 mmol/L of blood as per institution protocol which utilized a citrated-replacement fluid containing 140 mmol/L sodium and 18.0 mmol/L citrate (Regiocit, Baxter International Inc., Deerfield, Illinois, USA) administered pre-blood pump. 1 Citrate dose was titrated according to a sliding scale to target a circuit ionized-calcium of 0.26-0.40 mmol/L. A calcium-free dialysate (Biphozyl, Baxter International Inc., Deerfield, Illinois, USA) with 140 mmol/L sodium was employed.…”