[Continuous haemodialysis with citrate anticoagulation in patients with liver failure: three cases]

Regional citrate anticoagulation for continuous renal replacement therapy provides an efficient alternative to heparin as it reduces the likelihood of haemorrhage in critically ill patients with bleeding risk or coagulopathy and increases the haemofilter survival time. Liver failure is a classic contraindication of regional citrate anticoagulation since it carries the risk of citrate accumulation and its metabolic complications, although it could be attractive for this population of patients with high bleeding risk. We report three cases of continuous haemodialysis with regional citrate anticoagulation performed in patients with severe acute liver failure, without accumulation in two cases and with a suspected beginning of accumulation in the third case. For these patients, close monitoring of the total-to-ionized calcium ratio, pH and anion gap is particularly essential to control the safety of citrate infusion. Increasing effluent flow rate eliminates more calcium-bound citrate and therefore limits citrate accumulation and its consequences.