Regional Citrate Anticoagulation in Pediatric Patients: Dealing with Practice Points

Background: Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) has been shown to be safe and effective both in adults and children. The equipment and the solutions available in the pediatric setting are the same as in adults. Summary: Currently three commercially available citrate formulations for RCA during continuous renal replacement therapy CRRT are present: concentrated (4% trisodium citrate, 136 mmol/L), semi-concentrated (anticoagulant dextrose-A, ACD-A, 75 mmol/L) and diluted (Prismocitrate/Regiocit, 18 mmol/L). RCA is delivered as a predilution infusion solution; therefore, its volume in dedicated commercially available citrate solutions impacts continuous renal replacement (CRRT) dose, filtration fraction, circuit pressures, and fluid flow. These aspects represent crucial details in the pediatric setting, and their relevance is more important as the smaller the patient's body weight is. Thus, when RCA is prescribed in children, the blood pump flow rate, the dose, the load and the concentration of citrate, and the patient's ability to metabolize citrate should be considered carefully and specifically contextualized by the citrate concentration available in each center. This technical review will describe these practice concepts that should be known in detail by the clinician approaching RCA in the pediatric setting. Key messages: Citrate "dose" is the citrate concentration in the blood running in the CRRT circuit. Citrate "load" represents the mass of citrate that is delivered to the circuit per each treatment hour. For a given citrate dose and blood flow rate, very different CRRT settings, sodium loads, filtration fractions, and dialytic doses are delivered by choosing the different formulations.