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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 |
