Safety and efficacy of low-dose initial citrate infusion for continuous kidney replacement therapy in critically ill...

Circuit survival (CS) is critical for the maintenance of continuous kidney replacement therapy (CKRT). Regional citrate anticoagulation (RCA) is widely used, effective, and relatively safe; however, it is associated with complications such as citrate accumulation (CA). We aimed to analyze how a lower citrate infusion dose (CID) protocol could impact CS and risks for CA.

This retrospective single-center cohort study compared the efficacy and safety of standard CID (3.0 mmol/L) and low CID (2.2-2.5 mmol/L) at initial administration in patients receiving RCA for CKRT in a pediatric intensive care unit.

A total of 127 patients received 239 circuits (115 circuits in 55 recipients of standard CID, and 124 filters in 72 recipients of low CID). When filter life was limited to 72 h, median CS for all filters was similar between the standard and low CID groups (51.0 h [IQR: 25.0-72.0] vs. 49.5 h [IQR: 24.0-72.0]; p = 0.857). CS was also similar in circuits terminated due to clotting (standard CID: 38.0 h [IQR: 20.0-58.0], low CID: 37.5 h [IQR: 18.0-55.0]). Recipients of the low CID protocol had significantly lower frequencies of metabolic alkalosis, CA, and hypocalcemia. Multivariate regression identified two independent CA risk factors: longer circuit runtime (OR 1.013, 95% CI 1.002-1.025) and higher weight-adjusted blood flow rates (OR 1.208, 95% CI 1.022-1.427).

Administering a low CID when initializing RCA significantly reduces the likelihood of citrate-related complications while maintaining anticoagulant efficacy.