Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Mar;38(2):473-480.
doi: 10.1007/s40620-024-02201-5. Epub 2025 Feb 1.

Sustained Low-Efficiency Dialysis (SLED) with Regional Citrate Anticoagulation (RCA) and new dialysis equipment: a prospective study with serum citrate measurements and electrolyte monitoring

Francesca Di Mario  1 , Giuseppe Regolisti  2 , Filippo Fani  3 , Brenda Menegazzo  4 , Cristina Zambrano  5 , Paolo Greco  6 , Caterina Maccari  6 , Tommaso Di Motta  6 , Giuseppe Vizzini  7 , Chiara Italiano  7 , Enrico Fiaccadori  6
Affiliations

Sustained Low-Efficiency Dialysis (SLED) with Regional Citrate Anticoagulation (RCA) and new dialysis equipment: a prospective study with serum citrate measurements and electrolyte monitoring

Francesca Di Mario et al. J Nephrol. 2025 Mar.

Abstract

Background: Sustained-Low Efficiency Dialysis (SLED) is an increasingly used Kidney Replacement Therapy (KRT) modality in critically ill patients. This study was aimed at evaluating the safety and efficacy of simplified Regional Citrate Anticoagulation (RCA) for SLED using new hemodialysis equipment.

Methods: The 8-hour SLED sessions were performed with a Surdial X Nipro® hemodialysis machine and a cellulose triacetate filter. A concentrated citrate solution (ACD-A) was infused in predilution with a target circuit citrate concentration of 2.5-3 mmol/L. Blood recalcification in the extracorporeal circuit mainly occurred through the backfiltration phenomenon by dialysis fluid (Ca2+ 1.5 mmol/L). Serum citrate levels were directly measured during KRT by enzymatic methods and an extensive daily laboratory workup was performed. Changes in laboratory variables at the end of the SLED sessions were analyzed with mixed-effects linear models for repeated measures.

Results: Eighty-one SLED treatments were performed in 27 patients (APACHE II score 21 ± 6). The prescribed duration was attained for the majority of the treatments (72/81, 88%). No major bleeding episodes or side effects of citrate accumulation occurred. While calcium infusion was needed in 19/81 SLED sessions (23%), phosphate and magnesium supplementation was necessary following about 25% of all SLED sessions.

Conclusions: Our simplified regional citrate anticoagulation protocol for SLED with a new "conventional" dialysis machine resulted safe and effective, also for critically ill patients, ensuring a good match between the prescribed and delivered dialysis dose. Close electrolyte monitoring and early supplementation allowed to tailor the dialysis prescription to the patient's actual needs, while avoiding KRT-related complications.

Keywords: Acute kidney injury (AKI); Kidney replacement therapy (KRT); Regional citrate anticoagulation (RCA); Sustained low-efficiency dialysis (SLED).

PubMed Disclaimer

Conflict of interest statement

Declarations. Conflict of interest: The authors have no competing interests to declare that are relevant to the content of this article. Ethical approval: All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the local Ethics Committee (AVEN n° 3655, January 22nd, 2019). Informed consent to participate: Written informed consent was obtained from all patients.

References

    1. Levine Z, Vijayan A (2023) Prolonged intermittent kidney replacement therapy. Clin J Am Soc Nephrol 18(3):383–391. https://doi.org/10.2215/CJN.04310422 - DOI - PubMed - PMC
    1. Clark EG, Vijayan A (2023) How I prescribe prolonged intermittent renal replacement therapy. Crit Care 27(1):88. https://doi.org/10.1186/s13054-023-04389-7 - DOI - PubMed - PMC
    1. Pistolesi V, Morabito S, Pota V et al (2023) Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission. J Anesth Analg Crit Care 3(1):7. https://doi.org/10.1186/s44158-023-00091-w - DOI - PubMed - PMC
    1. Fiaccadori E, Regolisti G, Cademartiri C et al (2013) Efficacy and safety of a citrate-based protocol for sustained low-efficiency dialysis in AKI using standard dialysis equipment. Clin J Am Soc Nephrol 8(10):1670–1678. https://doi.org/10.2215/CJN.00510113 - DOI - PubMed - PMC
    1. Di Mario F, Regolisti G, Di Maria A et al (2021) Sustained low-efficiency dialysis with regional citrate anticoagulation in critically ill patients with COVID-19 associated AKI: a pilot study. J Crit Care 63:22–25. https://doi.org/10.1016/j.jcrc.2021.01.013 - DOI - PubMed - PMC

MeSH terms

LinkOut - more resources