What is the preferred anticoagulant, Trisodium Citrate (TSC) or PrismaSate (Generic name: not specified, likely a citrate-based solution), for Continuous Renal Replacement Therapy (CRRT)?

Regional Citrate Anticoagulation is Preferred Over Trisodium Citrate for CRRT

Regional citrate anticoagulation should be used rather than heparin for CRRT in patients without contraindications to citrate, as it significantly reduces bleeding risk while maintaining equivalent circuit survival and metabolic safety. 1

Understanding the Question Context

The comparison appears to reference "PrismaSate" versus "trisodium citrate," but this reflects a misunderstanding of CRRT anticoagulation terminology. PrismaSate is a commercially available dialysate/replacement fluid used with citrate anticoagulation protocols, not an alternative anticoagulant itself. The actual clinical decision is between regional citrate anticoagulation (which uses trisodium citrate solutions) versus heparin anticoagulation. 2

Primary Recommendation: Regional Citrate Anticoagulation

The 2012 KDIGO guidelines explicitly recommend regional citrate anticoagulation over heparin for CRRT in patients without citrate contraindications (Grade 2B). 1 This recommendation is based on:

• Significantly reduced bleeding risk (RR 0.32-0.34) compared to heparin, representing a 66-68% reduction in major bleeding events 3, 4
• Extended filter lifespan of approximately 14.5 hours longer than heparin, with median survival of 61.5 hours and 61% survival at 48 hours 2, 4
• No increase in mortality at 28 or 90 days compared to heparin 4

Contraindications to Citrate Anticoagulation

Avoid citrate in patients with: 1, 5

• Severe liver dysfunction (impaired citrate metabolism leading to accumulation)
• Severe shock with muscle hypoperfusion (reduced citrate clearance)
• Signs of citrate accumulation (total calcium >3 mmol/L or increasing calcium replacement requirements) 6

For these patients, use unfractionated or low-molecular-weight heparin instead. 1

Metabolic Safety Profile

Contrary to historical concerns, citrate anticoagulation does not significantly increase metabolic complications when properly monitored: 4

• Metabolic alkalosis occurs at similar rates to heparin (RR 1.46, p=0.470), affecting >50% of patients but reversible by increasing dialysate flow 7, 4
• Metabolic acidosis shows no significant difference (RR 1.71, p=0.054) 4
• Hypocalcemia is more common with citrate (RR 3.81) but clinically manageable without adverse events when protocols include systematic calcium monitoring 3, 4

Implementation Protocol

Use a standardized citrate protocol with the following monitoring: 8, 5

• Post-filter ionized calcium maintained <0.5 mmol/L to ensure adequate anticoagulation 2
• Systemic ionized calcium maintained at 1.1 mmol/L via central calcium gluconate infusion 2
• Systemic acid-base balance monitoring, particularly in high-risk patients 8, 5
• Serum sodium levels to prevent hypernatremia 8
• Magnesium levels as magnesium-citrate complexes are lost in effluent 8

Practical Citrate Dosing

Modern simplified protocols use: 2, 6

• 2% trisodium citrate at 250 mL/h (adjusted to maintain post-filter ionized calcium <0.5 mmol/L) 2
• 4% trisodium citrate with weight-based dosing (dialysate flow ~2 L/hr for average body size, adjusted for patient weight) 6
• Calcium-free dialysate with customized electrolyte composition 7

Special Populations

For patients with increased bleeding risk: Regional citrate anticoagulation is preferred over no anticoagulation (Grade 2C), as it maintains circuit patency without systemic anticoagulation effects. 1, 8

For heparin-induced thrombocytopenia (HIT): All heparin must be stopped immediately; use direct thrombin inhibitors (argatroban 0.7-1.7 μg/kg/min) or Factor Xa inhibitors instead (Grade 1A). 1, 5

Cost-Effectiveness

Citrate anticoagulation provides significant cost reduction compared to heparin due to extended filter lifespan (80.2 vs 30.2 hours), despite requiring specialized dialysate solutions and monitoring. 7

Critical Implementation Caveat

Citrate is not FDA-approved as an anticoagulant for CRRT in the United States, and commercially available citrate solutions are hypertonic, potentially increasing metabolic complication risk. 5 This necessitates strict adherence to standardized protocols with adequate staff education to prevent prescription errors. 8, 5