Table 2.

Citrate anticoagulation: risk factors, suggested monitoring and strategies for the prevention and treatment of citrate accumulation

Risk factors for citrate accumulation
Severity of liver failure
Hypoxaemia
Citrate-containing blood products (blood transfusions, fresh frozen  plasma)
Suggested monitoringa
pH, bicarbonate and anion gap
Total and ionized calcium
Total to ionized calcium ratio (abnormal >2.5)
Prevention and treatment strategiesa
Decrease citrate administration
Decrease blood flow rate
Target higher post-filter calcium value
Avoid citrate-containing blood products
Increase citrate clearance
Increase convective dialysis dose
Increase diffusive dialysis dose
Treat hypoxaemia if present
For hypocalcaemia
Increase calcium delivery before correcting metabolic acidosis and  supplement hypomagnesaemia
For metabolic acidosis
Increase bicarbonate administration in replacement and dialysis    solutions if required and check sodium levels if sodium    bicarbonate is administered
Consider alternatives to citrate if metabolic complications remain  despite the above measures

^aTo be adapted according to the degree of hepatic insufficiency.