Journal article
Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management
Critical care (London, England), Vol.30(1), 358
12/2026
DOI: 10.1186/s13054-026-06066-x
PMID: 42129846
Abstract
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.
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.
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.
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.
Details
- Title: Subtitle
- Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management
- Creators
- Rita Jacobs - University of AntwerpAntoine Schneider - University Hospital of LausanneEric Hoste - Ghent University HospitalWalter Verbrugghe - University of AntwerpSean Bagshaw - University of AlbertaMax Bell - Karolinska University HospitalWillem Boer - Ziekenhuis Oost-LimburgJosee Bouchard - Université de MontréalMarcus Broman - Skåne University HospitalBrendan Crawford - University of Arkansas Medical CenterSascha David - University of ZurichFrancesca Di Mario - Ospedale di ParmaOlivier Joannes-Boyau - Centre Hospitalier Universitaire de BordeauxMichael Joannidis - Innsbruck Medical UniversityCatherine Joseph - Baylor College of MedicineKyle A Merrill - University of IowaMarlies Ostermann - Guy's and St Thomas' NHS Foundation TrustPaul Palevsky - University of PittsburghKaren Papez - Phoenix Children's HospitalJohn Prowle - Queen Mary University of LondonOleksa Rewa - University of AlbertaZaccaria Ricci - Meyer Children's HospitalStella Shin - Children's Healthcare of AtlantaBalazs Szamosfalvi - University of Alabama at BirminghamAshita Tolwani - University of MichiganGianluca Villa - Azienda Ospedaliero-Universitaria CareggiMeint Volbeda - University Medical Center GroningenThomas Rimmelé - Hôpital PasteurPhilippe G Jorens - University of Antwerp
- Resource Type
- Journal article
- Publication Details
- Critical care (London, England), Vol.30(1), 358
- DOI
- 10.1186/s13054-026-06066-x
- PMID
- 42129846
- NLM abbreviation
- Crit Care
- ISSN
- 1466-609X
- eISSN
- 1466-609X
- Publisher
- Springer Nature
- Grant note
This research received no external funding.
- Language
- English
- Electronic publication date
- 05/13/2026
- Date published
- 12/2026
- Academic Unit
- Nephrology, Dialysis and Transplantation; Stead Family Department of Pediatrics
- Record Identifier
- 9985164532502771
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