Table 1.
Characteristics of the main regional citrate anticoagulation protocols
| Citrate Solution/RRT Modality | Blood Flow and Citrate Infusion Rates | Citrate Solution | Dialysate | Replacement Fluid | Reference |
|---|---|---|---|---|---|
| High concentration (hypertonic in sodium) | |||||
| Postdilution CVVH | Qb=150–300 ml/min; citrate=38–77 ml/h (38–77 mmol/h) | TSC=1000 mmol/L; Na+=3000 mmol/L | N/A | Low sodium (120 mmol/L); buffer-free; calcium-free | Monchi et al. (15) |
| Predilution CVVHDF | Qb=150 ml/min; citrate 150 ml/h (16.9 mmol/h) | ACD-A: citrate=112.9 mmol/L (TSC=2.2%/citric acid=0.8%); Na+=224 mmol/L | Low sodium (132 mmol/L); lactate=40 mmol/L; calcium containing (1.25 mmol/L) | Isotonic saline (Na+=154 mmol/L) | Gupta et al. (103) |
| Postdilution CVVHDF | Qb=125 ml/min; citrate=190 ml/h (25.3 mmol/h) | TSC=133 mmol/L; Na+=399 mmol/L | Low sodium (117 mmol/L); buffer-free; calcium-free | Low sodium (117 mmol/L); variable bicarbonate (33–50 mmol/L according to A-B status); calcium-free | Kutsogiannis et al. (16) |
| Postdilution CVVH | Qb=220 ml/min; citrate flow rate not reported (target citratemia=3 mmol/L) | TSC/citric acid=500 mmol/L; Na+=1352 mmol/L | N/A | Low sodium (109.5 mmol/L); buffer-free combined with a bicarbonate-buffered solution according to A-B status; Ca2+=1.81 mmol/L | Oudemans-van Straaten et al. (18) |
| CVVHD | Qb=80–120 ml/min; citrate=140–205 ml/h (19–27.9 mmol/h) | TSC=136 mmol/L; Na+=408 mmol/L | Low sodium (133 mmol/L); low bicarbonate (20 mmol/L); calcium-free | N/A | Morgera et al. (46) |
| CVVHD | Qb=150–200 ml/min; citrate flow rate not reported (target citratemia=4 mmol/L) | TSC=136 mmol/L; Na+=408 mmol/L | Low sodium (133 mmol/L); low bicarbonate (20 mmol/L); calcium-free | N/A | Kalb et al. (49) |
| Predilution CVVHDF | Qb=120 ml/min; citrate=700 ml/h (19.75 mmol/h) | ACD-A–based diluted citrate solution=28.22 mmol/L; Na+=163.3 mmol/L; bicarbonate=30 mmol/L | Low sodium (133 mmol/L); low bicarbonate (20 mmol/L); calcium-free | N/A | Mariano et al. (47) |
| CVVHD | Qb=75–100 ml/min; citrate=35–45 ml/h (39.3–50.6 mmol/h) | TSC/citric acid=743/381 mmol/L; Na+=2229 mmol/L | Low to standard sodium (129–140 mmol/L); variable bicarbonate (13.2–34.3 mmol/L according to A-B status); calcium containing (1.75 mmol/L) | N/A | Saner et al. (57) |
| SLED | Qb 200 ml/min; citrate 180 ml/h (24.5 mmol/h) | TSC=136 mmol/L; Na+=408 mmol/L | Standard dialysate (Genius system; 180–200 ml/min); calcium containing (1.0 mmol/L) | N/A | Morgera et al. (105) |
| SLED | Qb=250 ml/min; citrate=231–261 ml/h (31.4–35.5 mmol/h) | TSC=136 mmol/L; Na+=408 mmol/L | Standard sodium and bicarbonate dialysate (300 ml/min); calcium-free | N/A | Clark et al. (86) |
| SLED-HDF | Qb=130 ml/min; citrate=1350 ml/h (38.1 mmol/h) | ACD-A–based diluted citrate solution=28.22 mmol/L; Na+=163.3 mmol/L; bicarbonate=30 mmol/L | Low sodium (133 mmol/L); low bicarbonate (20 mmol/L); calcium-free | N/A | Mariano et al. (47) |
| SLED | Qb=200 ml/min; citrate=200–400 ml/h (22.6–45.2 mmol/h) | ACD-A: citrate=112.9 mmol/L (TSC=2.2%/citric acid=0.8%); Na+=224 mmol/L | Cocurrent flow standard dialysate (300 ml/min); calcium containing (1.25 mmol/L) | N/A | Fiaccadori et al. (51) |
| Low concentration (isotonic in sodium) | |||||
| Predilution CVVHDF | Qb=100–150 ml/min; citrate=1000–2000 ml/h (18–46 mmol/h) | TSC=18 or 23 mmol/L obtained by diluting a TSC 4% citrate solution; Na+=140 mmol/L | Standard sodium (140 mmol/L); low bicarbonate (25 mmol/L); calcium-free | N/A | Tolwani et al. (62) |
| Predilution CVVH | Qb=100–200 ml/min; citrate=2000–4000 ml/h (26–52 mmol/h) | TSC=13 mmol/L; Na+=140 mmol/L | N/A | N/A | Hetzel et al. (19) |
| Pre- and postdilution CVVH | Qb=130–150 ml/min; citrate=1560–1800 ml/h (18.7–21.6 mmol/h) | TSC/citric acid=10/2 mmol/L; Na+=136 mmol/L | N/A | Standard sodium (140 mmol/L); standard bicarbonate (32 mmol/L); calcium containing (1.75 mmol/L) | Morabito et al. (14) |
| Predilution CVVH | Qb=150 ml/min; citrate=2500 ml/h (30 mmol/h) | TSC/citric acid=10/2 mmol/L; Na+=136 mmol/L | N/A | N/A | Shum et al. (64) |
| Predilution CVVH | Qb=180 ml/min; citrate=2400 ml/h (31.9 mmol/h) | TSC=13.3 mmol/L; Na+=140 mmol/L | N/A | N/A | Nurmohamed et al. (50) |
| Pre- and postdilution CVVHDF | Qb=140 ml/min; citrate=1000 ml/h (18 mmol/h) | TSC=18 mmol/L; Na+=140 mmol/L | Standard sodium (140 mmol/L); standard bicarbonate (30 mmol/L); calcium containing (1.25 mmol/L); phosphate containing (HPO42+=1.2 mmol/L) | Standard sodium (140 mmol/L); standard bicarbonate (30 mmol/L); calcium containing (1.25 mmol/L); phosphate containing (HPO42−=1.2 mmol/L) | Morabito et al. (66) |
The definitions SLED and SLED-HDF have been maintained as in the original articles; both treatment modalities may be included under the term prolonged intermittent RRT (PIRRT). CVVH, continuous venovenous hemofiltration; CVVHDF, continuous venovenous hemodiafiltration; CVVHD, continuous venovenous hemodialysis; SLED, sustained low-efficiency dialysis; SLED-HDF, sustained low-efficiency hemodiafiltration; Qb, blood flow rate; TSC, trisodium citrate; ACD-A, anticoagulant citrate dextrose solution A; N/A, not applicable.