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Regional Citrate Anticoagulation in Pediatric Patients: Dealing with Practice Points

Zaccaria Ricci1,2, Akash Deep3, Stuart L Goldstein4

  • 1Department of Emergency and Critical Care, Anesthesia and Pediatric Intensive Care Unit, Meyer Children's Hospital, IRCCS, Florence, Italy, zaccaria.ricci@unifi.it.

Blood Purification
|October 3, 2025
PubMed

Insights

Regional citrate anticoagulation (RCA) is safe for pediatric continuous renal replacement therapy (CRRT). Careful consideration of citrate concentration and patient factors is crucial for safe and effective RCA in children.

Area of Science:

  • Pediatric Nephrology
  • Critical Care Medicine
  • Pharmacology

Background:

  • Regional citrate anticoagulation (RCA) is a safe and effective method for continuous renal replacement therapy (CRRT) in both adult and pediatric populations.
  • The same equipment and solutions are utilized for RCA in pediatric and adult CRRT.
  • Understanding the nuances of RCA in pediatrics is essential due to potential impacts on CRRT parameters.

Purpose of the Study:

  • To review the practice concepts of RCA in the pediatric setting.
  • To highlight the importance of citrate concentration and its impact on CRRT parameters in children.
  • To provide clinicians with detailed knowledge for approaching RCA in pediatric patients.

Main Methods:

  • Review of available literature and commercial citrate formulations for RCA in CRRT.
  • Analysis of the impact of different citrate concentrations on CRRT dose, filtration fraction, circuit pressures, and fluid flow.
  • Discussion of factors to consider when prescribing RCA in children, including citrate dose, load, concentration, and patient metabolism.

Main Results:

  • Three commercial citrate formulations for RCA exist: concentrated (4%), semi-concentrated (ACD-A, 75 mmol/L), and diluted (18 mmol/L).
  • The volume of predilution RCA infusion impacts CRRT dose, filtration fraction, circuit pressures, and fluid flow, with greater relevance in smaller patients.
  • Different citrate formulations lead to variations in CRRT settings, sodium loads, filtration fractions, and dialytic doses for a given citrate dose and blood flow rate.

Conclusions:

  • The choice of citrate formulation significantly influences CRRT delivery in pediatric patients.
  • Clinicians must carefully consider blood pump flow rate, citrate dose, load, concentration, and the patient's metabolic capacity.
  • Contextualizing RCA prescription based on available citrate concentrations is critical for optimizing outcomes in pediatric CRRT.
Abstract

Keywords:
Filtration fractionPediatric continuous renal replacement therapyRegional citrate anticoagulation

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