Recommendations for Citrate Dosing in Pediatric CRRT
For pediatric patients requiring continuous renal replacement therapy (CRRT), regional citrate anticoagulation should be dosed at an initial citrate infusion dose of ≥2.7 mmol per liter of patient blood flow to achieve optimal filter life while monitoring for potential citrate accumulation. 1
Citrate Dosing Protocol
- Initial citrate dosing should follow the formula: citrate 3% rate (ml/h) ≈ blood flow rate (ml/min) × 2, which reliably achieves adequate anticoagulation in the extracorporeal circuit 2
- Target a prefilter ionized calcium (iCa) level of ≤0.4 mmol/L to effectively anticoagulate the CRRT circuit, which typically requires a prefilter serum citrate concentration of approximately 6 mmol/L 3
- Post-filter iCa level of ≤0.30 mmol/L reliably predicts adequate anticoagulation with an activated coagulation time (ACT) >120 seconds 2
Monitoring Parameters
- Monitor post-filter ionized calcium levels regularly to assess adequacy of anticoagulation 2
- Measure systemic ionized calcium levels frequently to detect hypocalcemia, which is more common with citrate anticoagulation 4
- Monitor acid-base balance regularly, especially in patients at high risk for citrate accumulation (those with liver dysfunction) 5
- For patients on CRRT >72 hours, increase vigilance for citrate accumulation as longer duration is associated with greater odds of accumulation (OR 2.17; 95% CI 1.01-4.68) 1
- Pay special attention to patients with elevated initial lactate levels, as this is associated with an 18% greater hazard of developing citrate accumulation 1
Benefits of Regional Citrate Anticoagulation
- Regional citrate anticoagulation significantly decreases the risk of bleeding compared to heparin (RR 0.34; 95% CI 0.17-0.65) 4
- Citrate provides similar circuit survival time compared to heparin anticoagulation 4
- Citrate anticoagulation can be safely used in pediatric patients with proper monitoring protocols 2, 1
Special Considerations
- When calculating total energy provision for patients on CRRT, include additional calories from citrate (3 kcal/g) to avoid overfeeding 5
- Energy contribution from citrate can be substantial, with studies reporting between 115-1300 kcal/day depending on the type and rate of fluids used 5
- For patients requiring temporary discontinuation of CRRT (for surgeries or procedures), a citrate-based self-circulation anticoagulation protocol can maintain circuit patency 6
- Warming the dialysate helps maintain hemodynamic stability in pediatric patients receiving CRRT 5, 7
Potential Complications and Management
- Citrate lock syndrome (characterized by increasing total-to-ionized calcium ratio) occurred in 6.3% of filters in a multicenter study but resolved without termination of CRRT 1
- Monitor for hypocalcemia, metabolic alkalosis, and acid-base disturbances regularly during citrate anticoagulation 5
- In patients with liver dysfunction, citrate metabolism may be impaired, increasing the risk of citrate accumulation and metabolic complications 5
By following these evidence-based recommendations for citrate dosing in pediatric CRRT, clinicians can achieve effective anticoagulation while minimizing bleeding risk and metabolic complications.