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Background <p>Regional citrate anticoagulation (RCA) is recommended by guidelines over systemic heparinization for continuous renal replacement therapy (CRRT). However, its use in patients with impaired citrate metabolism poses specific challenges and standardized guidance for managing RCA-related metabolic complications remains lacking.</p> Methods <p>A modified Delphi study was conducted according to a predefined protocol and reported in adherence with the CREDES (Conducting and REporting of DElphi Studies) checklist. The international expert panel comprised 29 clinicians and researchers from Europe, United States and Canada, with recognized expertise in RCA for CRRT in critically ill patients. Three iterative survey rounds were conducted to obtain agreement with proposed statements.</p> Results <p>Twenty-three experts completed all Delphi rounds, achieving consensus on twenty-two statements. RCA was considered feasible in patients with liver dysfunction, severe shock, or hyperlactatemia, with close monitoring and citrate dosing adjustment. Citrate accumulation can be prevented and managed using a stepwise approach, focused on reducing citrate delivery and discontinuing RCA in cases of overt accumulation. Metabolic alkalosis and electrolyte disturbances were identified as relevant but manageable complications, underscoring the need for individualizing CRRT settings.</p> Conclusion <p>These consensus statements support the use of RCA during CRRT in critically ill patients with impaired citrate metabolism and provide practical guidance for monitoring and management of metabolic complications. However they reflect expert opinion, especially for questions with limited data and low-level evidence.</p>

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Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年5月13日

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  • Rita Jacobs,
  • Antoine Schneider,
  • Eric Hoste,
  • Walter Verbrugghe,
  • Sean Bagshaw,
  • Max Bell,
  • Willem Boer,
  • Josee Bouchard,
  • Marcus Broman,
  • Brendan Crawford,
  • Sascha David,
  • Francesca Di Mario,
  • Olivier Joannes-Boyau,
  • Michael Joannidis,
  • Catherine Joseph,
  • Kyle A. Merrill,
  • Marlies Ostermann,
  • Paul Palevsky,
  • Karen Papez,
  • John Prowle,
  • Oleksa Rewa,
  • Zaccaria Ricci,
  • Stella Shin,
  • Balazs Szamosfalvi,
  • Ashita Tolwani,
  • Gianluca Villa,
  • Meint Volbeda,
  • Thomas Rimmelé,
  • Philippe G. Jorens

摘要

Background

Regional citrate anticoagulation (RCA) is recommended by guidelines over systemic heparinization for continuous renal replacement therapy (CRRT). However, its use in patients with impaired citrate metabolism poses specific challenges and standardized guidance for managing RCA-related metabolic complications remains lacking.

Methods

A modified Delphi study was conducted according to a predefined protocol and reported in adherence with the CREDES (Conducting and REporting of DElphi Studies) checklist. The international expert panel comprised 29 clinicians and researchers from Europe, United States and Canada, with recognized expertise in RCA for CRRT in critically ill patients. Three iterative survey rounds were conducted to obtain agreement with proposed statements.

Results

Twenty-three experts completed all Delphi rounds, achieving consensus on twenty-two statements. RCA was considered feasible in patients with liver dysfunction, severe shock, or hyperlactatemia, with close monitoring and citrate dosing adjustment. Citrate accumulation can be prevented and managed using a stepwise approach, focused on reducing citrate delivery and discontinuing RCA in cases of overt accumulation. Metabolic alkalosis and electrolyte disturbances were identified as relevant but manageable complications, underscoring the need for individualizing CRRT settings.

Conclusion

These consensus statements support the use of RCA during CRRT in critically ill patients with impaired citrate metabolism and provide practical guidance for monitoring and management of metabolic complications. However they reflect expert opinion, especially for questions with limited data and low-level evidence.