Table 2.

Potential acid-base and electrolyte complications during regional citrate anticoagulation and preventive measures

ComplicationMechanismPreventive Measures
Metabolic alkalosisExcessive buffer load related to high citrate delivery to the patient (imbalance between citrate infusion rate and citrate removal with the effluent) and/or inadequate matching of RCA solutions (citrate concentration, bicarbonate concentration in dialysate/replacement fluid) in the case of CRRTDecrease citrate infusion rate by reducing blood flow and/or reducing target citrate dose (with a corresponding higher circuit ionized calcium)
Increase citrate and bicarbonate losses by increasing dialysate/replacement fluid flow rate
Reduce bicarbonate concentration in the dialysate/replacement fluid
Remove or limit exogenous buffer sources (acetate in total parenteral nutrition solutions and citrate-containing blood products)
Metabolic acidosisInadequate buffer supply (imbalance between citrate/bicarbonate delivered to the patient and citrate/bicarbonate removed with the effluent)After excluding inadequate citrate metabolism, increase citrate delivery to the patients by increasing citrate infusion rate and/or increasing target citrate dose, reduce citrate and bicarbonate losses by reducing dialysate/replacement fluid flow rate, or increase bicarbonate concentration in the dialysate/replacement fluid or start bicarbonate supplementation by systemic infusion
Inadequate citrate metabolism (i.e., severe liver failure and septic or cardiogenic shock with tissue hypoperfusion) preventing bicarbonate productionIn the presence of signs of citrate accumulation, reduce or stop citrate infusion and/or increase citrate loss by increasing dialysate/replacement fluid flow rate or switch to a standard bicarbonate dialysate/replacement fluid and/or start bicarbonate supplementation by systemic infusion
Systemic ionized hypercalcemiaExcessive calcium replacementReduce calcium infusion rate
Systemic ionized hypocalcemiaInadequate calcium replacementAfter excluding inadequate citrate metabolism, increase calcium infusion rate (check infusion pump to exclude technical issues)
Inadequate citrate metabolism preventing calcium release from calcium-citrate complexesIn the presence of signs of citrate accumulation, increase calcium infusion rate and consider the measures suggested for citrate accumulation
HypernatremiaUse of high-concentration trisodium citrate solutions without adequate lowering of sodium concentration in the dialysate/replacement fluidUse a low-sodium dialysate/replacement fluid in protocols based on hypertonic citrate solutions
HyponatremiaAccidental omission of hypertonic citrate solution in protocols adopting hypotonic dialysate/replacement fluid (rarely observed)Verify the correct matching of RCA solutions
HypomagnesemiaInadequate magnesium replacementIncrease magnesium replacement (check infusion pump to exclude technical issues)
  • RCA, regional citrate anticoagulation; CRRT, continuous RRT.