Simplified citrate anticoagulation for continuous renal replacement therapy

Background. Regional anticoagulation with trisodium citrate is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) fo r patients with contraindications to heparin. However, because of the metab olic complications of trisodium citrate, it is a complicated technique requ iring specialized dialysis solutions. We have designed a simplified protoco l for citrate regional anticoagulation for CRRT. Methods. Two percent trisodium citrate was delivered at 250 mL/h via the pr efilter port of a COBE PRISMA device, with the rate adjusted to maintain a postfilter ionized calcium (iCa(++)) <0.5 mmol/L. A central calcium glucona te infusion was used to maintain a systemic iCa(++) at 1.1 mmol/L. A standa rd dialysate solution consisting of 0.9% saline, KCl 3 mmol/L. and MgSO4 mm ol/L was delivered at 1000 mL/h. We retrospectively reviewed the outcomes a nd complications associated with this protocol in 29 patients treated from July 1999 to October 1999, evaluating the frequency of clotting of the dial yzer, bleeding complications, citrate toxicity, and patient mortality. Results. The Kaplan-Meier curve for dialyzer survival demonstrated a 61% su rvival rate at 48 hours. There were no episodes of significant bleeding or citrate toxicity. Seventy-two percent of patients died for reasons unrelate d to CRRT. Conclusions. A CRRT protocol using regional 2% trisodium citrate anticoagul ation is not associated with significant bleeding complications or citrate toxicity, and represents a simplified approach compared with previous appli cations using 4% trisodium citrate.