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Outcomes of a Low-Dose Regional Citrate Anticoagulation Strategy in Continuous Kidney Replacement Therapy
Journal article   Open access   Peer reviewed

Outcomes of a Low-Dose Regional Citrate Anticoagulation Strategy in Continuous Kidney Replacement Therapy

Naga Sumanth R Gopireddy, Imran Khawaja, Sahil Grover, Gwyndolyn M. Radford, Mony Fraer, Jonathan M. Nizar, Lisa Antes and Benjamin R. Griffin
Kidney medicine, 101536
09/2026
DOI: 10.1016/j.xkme.2026.101536
url
https://doi.org/10.1016/j.xkme.2026.101536View
Published (Version of record) Open Access

Abstract

Rationale & Objective Regional citrate anticoagulation (RCA) is the guideline-recommended anticoagulation strategy for continuous kidney replacement therapy (CKRT), with target post-filter ionized calcium (iCa) concentrations of 1.0–1.4 mg/dL. Recent studies suggest higher post-filter iCa targets might reduce RCA-related complications while maintaining comparable filter life. The University of Iowa has historically employed a lower-dose RCA strategy emphasizing metabolic safety. We evaluated filter life and citrate-related complications under this permissive RCA strategy. Study Design Retrospective, single-center observational cohort study. Setting & Participants Adult patients receiving CKRT at the University of Iowa Hospitals and Clinics from 2022 to 2024, limited to the first three circuits per patient. Exposure RCA anticoagulation strategy. Outcomes The primary outcome was filter life. Secondary outcomes included filters lasting <24 hours, filters reaching maximum circuit life, citrate accumulation, and hypocalcemia. Analytical Approach Generalized estimating equation models accounted for multiple filters per patient and evaluated associations between anticoagulation strategy and filter life. RCA-only models evaluated associations of post-filter iCa and calculated pre-filter citrate concentration with filter life. Results We analyzed 724 filters from 386 patients. Median filter life was 32 hours with RCA and 27 hours without anticoagulation; low-dose RCA was associated with a modest filter life benefit (+5.0 hours; p=0.03) with low rates of hypocalcemia and citrate accumulation. Among RCA circuits, pre-filter citrate concentration independently predicted filter life whereas post-filter iCa showed limited association. Limitations Retrospective single-center design; inadequate data on cause of circuit termination; calculated rather than measured pre-filter citrate concentration. Conclusions A lower-dose RCA strategy had low rates of citrate-related complications and was associated with longer filter life than no anticoagulation, although filter-life benefit appeared attenuated relative to published studies using more intensive RCA protocols. Calculated pre-filter citrate concentration correlated with filter performance more consistently than measured post-filter iCa.

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