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Table 2 Metabolic derangements and adjustments during citrate anticoagulation

From: Clinical review: Patency of the circuit in continuous renal replacement therapy

Derangement Cause and signs Adjustment
Metabolic acidosis Insufficient removal of metabolic acids Increase continuous renal replacement therapy dose
  Anion gap increases (filtrate or dialysate flow) to 35 ml/kg per hour
  Loss of buffer substrate is higher than delivery Increase bicarbonate replacement or increase bicarbonate dialysate flow or give additional bicarbonate or increase citrate flow (cave accumulation)
  Citrate metabolism decreases (iCa decreases, totCa/iCa increases [more than 2.1–2.5], and anion gap increases) Decrease citrate delivery or stop increase dialysate or filtrate flow increase bicarbonate replacement or increase bicarbonate dialysate flow
Metabolic alkalosis Delivery of buffer substrate is higher than loss Decrease bicarbonate replacement or decrease bicarbonate dialysate flow or stop additional bicarbonate i.v. or decrease citrate flow (cave anticoagulation)
  Decreased loss of buffer due to a decline in filtrate flow Change filter Increase filtrate flow
Hypocalcemia Loss of calcium is higher than delivery (iCa decreases and totCa/iCa is normal) Increase i.v. calcium dose
  Citrate metabolism decreases (metabolic acidosis, totCa/iCa increases, and anion gap increases) Increase i.v. calcium dose, decrease or stop citrate delivery increase dialysate or filtrate flow, increase bicarbonate replacement or increase bicarbonate dialysate flow
Hypercalcemia Delivery of calcium is higher than loss Decrease i.v. calcium dose
Hypernatremia Delivery of sodium is higher than loss Recalculate default settings
   Protocol violation
   • decrease sodium replacement
   • decrease dialysate sodium content
   • decrease trisodium citrate flow
  Decreased loss of sodium due to a decline in filtrate flow Change filter
Hyponatremia Loss of sodium is higher than delivery Recalculate default settings
   Protocol violation
   • increase sodium replacement
   • increase dialysate sodium content
   • increase trisodium citrate flow
  1. iCa, ionized calcium; i.v., intravenous; totCa/iCa, ratio of total to ionized calcium.