A Prospective, Observational Study to Evaluate the Safety and Feasibility of Continuous Renal Replacement Therapy With Regional Citrate Anticoagulation in a Cohort Critical Ill Patients With Acute Kidney Injury and Presumed Absent Citrate Metabolism

Regional citrate anticoagulation (RCA) is the recommended anticoagulation strategy for continuous renal replacement therapy (CRRT). Traditionally, CRRT-RCA is not recommended in patients with advanced liver failure or in patients with severe hemodynamic shock due to the risk of citrate accumulation or citrate intoxication. However, since more than a decade more and more patients with advanced liver failure and severe hemodynamic shock undergo safely CRRT-RCA with an adapted CRRT protocol. The aim of this study is to evaluate the efficacy and safety of CRRT-RCA in patients with decreased citrate metabolism using an adapted protocol to maximize citrate elimination.

Inclusion criteria

• Need for renal replacement therapy in the ICU with any of the following criteria:
• anticipation of severely impaired citrate metabolism (serum lactate ≥ 5 mmol/l in patients with shock or requirement of a dextrose drip to prevent hypoglycemia or spontaneous INR > 3 and/or requirement of fresh frozen plasma to maintain INR < 3 in patients with cirrhosis or acute liver failure or acute on chronic liver failure)
• development of citrate toxicity under CRRT with RCA due to worsening citrate metabolism

Exclusion criteria

• Pregnancy
• A known hypersensitivity to citrate compounds
• Refusal of informed consent