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. 2017 Nov 19;21(1):281.
doi: 10.1186/s13054-017-1880-1.

Complications of regional citrate anticoagulation: accumulation or overload?

Antoine G Schneider  1   2 , Didier Journois  3 , Thomas Rimmelé  4   5
Affiliations

Complications of regional citrate anticoagulation: accumulation or overload?

Antoine G Schneider et al. Crit Care. .

Abstract

Regional citrate anticoagulation (RCA) is now recommended over systemic heparin for continuous renal replacement therapy in patients without contraindications. Its use is likely to increase throughout the world. However, in the absence of citrate blood level monitoring, the diagnosis of citrate accumulation, the most feared complication of RCA, remains relatively complex. It is therefore commonly mistaken with other conditions. This review aims at providing clarifications on RCA-associated acid-base disturbances and their management at the bedside. In particular, the authors wish to propose a clear distinction between citrate accumulation and net citrate overload.

Keywords: Acute kidney injury; Citrate accumulation; Complications of therapy; Continuous renal replacement therapy; Metabolic alkalosis; Regional citrate anticoagulation.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

AS received speaker honoraria from Fresenius Medical Care and Baxter Healthcare Corp. and consulting honoraria from B. Braun Melsungen AG. DJ has no competing interests to disclose. TR received speaker honoraria from Fresenius Medical Care, Baxter Healthcare Corp., and Bellco-Medtronic.

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Figures

Fig. 1
Fig. 1
“ON-OFF” anticoagulation effect of ionized hypocalcemia. The grey zone corresponds to the area of adequate anticoagulation. Target values indicated are only indicative and depend on the protocol used [12]
Fig. 2
Fig. 2
Schematic view of a CRRT circuit with regional citrate administration in CVVHD mode. Alternative modes can be used (postdilution CVVH, combined pre- and postdilution CVVH, CVVHDF, etc.) according to the protocol used. Citrate solution is administered at the beginning of the CRRT circuit. It forms citrate–calcium complexes, which are largely removed from the blood at the level of the filter. Only complexes which are not removed through the hemofilter return to the patient’s blood and need to be metabolized
Fig. 3
Fig. 3
Citrate calcium complex. The distance between calcium’s two positive charges corresponds to the distance between two citrate carboxylate radicals. A carboxylate radical remains unbound, providing residual anionic charge and a mild acidic effect. This acidifying effect would be much stronger in vitro, in the absence of ionized calcium
Fig. 4
Fig. 4
Theoretical relationship between blood citrate level and citrate load. a An increase in citrate load is not associated with an increase in blood citrate level until a threshold is reached. This threshold corresponds to the body’s capacity to metabolize citrate. b Certain circumstances, such as severe liver failure or circulatory shock, might result in a lower threshold corresponding to a decreased capacity to metabolize citrate (see text)
Fig. 5
Fig. 5
Consequences of citrate accumulation
See this image and copyright information in PMC

References

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