Skip to content


Critical Care

Open Access

Multicenter prospective observational study on safety and efficacy of regional citrate anticoagulation in CVVHD in the presence of liver failure: the Liver Citrate Anticoagulation Threshold Study (L-CAT)

  • T Slowinski1,
  • S Morgera2,
  • M Joannidis3,
  • T Henneberg4,
  • R Stocker5,
  • E Helset4,
  • K Andersen6,
  • M Wehner2,
  • J Kozik-Jaromin7,
  • S Brett8,
  • J Hasslacher3,
  • JF Stover5,
  • H Peters2,
  • HH Neumayer2 and
  • D Kindgen-Milles8
Critical Care201115(Suppl 1):P127

Published: 1 March 2011


Liver FailureHypercalcemiaMultiple Organ Dysfunction SyndromeRenal RecoverySevere Acidosis


Regional citrate anticoagulation in continuous venovenous hemodialysis (citrate-CVVHD) has become a widely used technique in the ICU, which decreases risk of bleeding. However, concern exists about safety of citrate in liver failure patients. The aim of our study was to evaluate safety and efficacy of regional citrate anticoagulation in ICU patients with normal and impaired liver function.


One hundred and thirty-three consecutive adult ICU patients were prospectively observed for 72 hours of citrate-CVVHD. Patients were stratified into three groups according to their serum bilirubin (mg/dl) (normal: ≤2, n = 47, mild: >2 to ≤7, n = 44, severe: >7, n = 42). Citrate-CVVHD was performed with variable treatment dose using the multiFiltrate device (Fresenius Medical Care, Germany). End-points for safety were: severe acidosis or alkalosis (pH ≤7.2; ≥7.55) and severe hypocalcemia or hypercalcemia (≤0.9; ≥1.5 mmol/l) of any cause. Endpoint for efficacy was the filter lifetime.


Main types of ICU admission were: 56% medical and 38% post-surgery. Liver failure was predominantly due to ischemia (39%) or multiple organ dysfunction syndrome (27%). The frequency of safety end-points of any cause did not differ between the three patient strata: severe alkalosis (normal: 2%, mild: 0%, severe: 5%; P = 0.41); severe acidosis (normal: 13%, mild: 16%, severe: 14%; P = 0.95); severe hypocalcemia (normal: 8%, mild: 16%, severe: 12%; P = 0.57); severe hypercalcemia (0% in all strata). Only in three patients was an increased ratio of total to ionized calcium (≥2.5) detected (2%). Overall filter lifetime was 49% after 72 hours; however, after censoring for discontinuation due to non-clotting causes (for example, renal recovery, death) 96% of all filters were running after 72 hours.


Our data demonstrate that citrate-CVVHD can be safely used in patients with liver dysfunction. Furthermore, it yields excellent filter patency and avoids bleeding, and thus can be recommended also in patients with liver dysfunction.

Authors’ Affiliations

Charité CCM, Berlin, Germany
Department of Nephrology, Charité CCM, Berlin, Germany
Department of Internal Medicine I, Medical University, Innsbruck, Austria
Department of Visceral and Transplant Surgery, Charité CVK, Berlin, Germany
Surgical Intensive Care, University Hospital, Zurich, Switzerland
Department of Acute Medicine, University Hospital, Oslo, Norway
Clinical Research, Fresenius Medical Care, Bad Homburg, Germany
Department of Anaesthesiology, University Hospital, Duesseldorf, Germany


© Slowinski et al. 2011

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.