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. 2023 May 29;10(1):23.
doi: 10.1186/s40779-023-00457-9.

Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus

Shu-Yuan Liu #  1 , Sheng-Yong Xu #  2 , Lu Yin #  3 , Ting Yang  4 , Kui Jin  5 , Qiu-Bin Zhang  6 , Feng Sun  7 , Ding-Yu Tan  8 , Tian-Yu Xin  1 , Yu-Guo Chen  9   10   11 , Xiao-Dong Zhao  12 , Xue-Zhong Yu  13 , Jun Xu  14 ; Emergency Medical Doctor Branch of the Chinese Medical Doctor Association
Collaborators, Affiliations

Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus

Shu-Yuan Liu et al. Mil Med Res. .

Abstract

Continuous renal replacement therapy (CRRT) is widely used for treating critically-ill patients in the emergency department in China. Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT. Regional citrate anticoagulation (RCA) has been shown to potentially be safer and more effective and is now recommended as the preferred anticoagulant method for CRRT. However, there is still a lack of unified standards for RCA management in the world, and there are many problems in using this method in clinical practice. The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues, including the advantages and disadvantages of RCA in CRRT anticoagulation, the principle of RCA, parameter settings for RCA, monitoring of RCA (mainly metabolic acid-base disorders), and special issues during RCA. Based on the latest available research evidence as well as the paneled experts' clinical experience, considering the generalizability, suitability, and potential resource utilization, while also balancing clinical advantages and disadvantages, a total of 16 guideline recommendations were formed from the experts' consensus.

Keywords: Anticoagulation; Citrate; Continuous renal replacement therapy; Emergency; Expert consensus; Guideline.

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Conflict of interest statement

All authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Chelation reaction of the trivalent anion of Citrate3− with an ionized calcium
Fig. 2
Fig. 2
Schematic diagram of citrate metabolism. When trisodium citrate is infused into the extracorporeal circulation, citrate-calcium complexes (CCC) is formed by the chelation reaction of ionized calcium (iCa) and Citrate3−. iCa is rapidly reduced to prevent clotting. About 30–60% of CCC molecules enter the effluent through the permeable membrane depending on different continuous renal replacement therapy (CRRT) modes and therapeutic doses. The residual CCC molecules return to the systemic circulation and are metabolized rapidly in body cells. The half-life of CCC under physiological conditions is only 5 min. CCC is eventually decomposed into bicarbonate through the tricarboxylic acid oxidation cycle (one molecule of citrate yields three molecules bicarbonate), and the iCa is released back into the blood
Fig. 3
Fig. 3
Schematic diagram of RCA in the CRRT system. Citrate is infused into the extracorporeal circulation before filter. Citrate-calcium complexes (CCC) is formed by the chelation reaction of ionized calcium (iCa) and Citrate3−. Partial CCC and iCa are removed by the filter. As a result, iCa in the filter is rapidly reduced to below 0.4 mmol/L, thus preventing clotting. The concentration of iCa in the filter is routinely monitored at the site behind the filter. Before the blood is returned to the body, additional iCa is infused to the blood in order to replenish the calcium removed to effluent by the filter. RCA regional citrate anticoagulation, CRRT continuous renal replacement therapy
See this image and copyright information in PMC

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