title: Continuous renal replacement therapy with regional citrate anticoagulation: do we really know the details?
abstract: OBJECTIVE
  A significant proportion of critically ill patients with acute kidney injury require continuous renal replacement therapy (CRRT). This article summarizes current evidence on the diagnosis and treatment of acute kidney injury. Regional citrate anticoagulation (RCA) is an emerging but complex technique. A variety of solutions and systems are currently used for RCA. Descriptions of the dosage and methods differ significantly and may cause confusion in everyday practice. This article reviews important scientific findings and highlights pharmacological and pathophysiological aspects of RCA, with a special emphasis on practical clinical issues regarding dosage and available citrate solutions.
  
  
  RESULTS
  RCA provides a similar or even longer circuit run, with manageable metabolic complications. Although large-scale multicentre trials are needed, there is increasing evidence for the benefits of citrate solutions in CRRT. International guidelines recommend using citrate anticoagulation rather than heparin in patients without contraindications against citrate.
  
  
  CONCLUSIONS
  RCA-CRRT is a technique that can be safely used in the majority of intensive care patients with severe multiple-organ failure. The range of citrate solutions available, the different methods in use--continuous venovenous haemofiltration, continuous venovenous haemodialysis and continuous venovenous haemodiafiltration--and the lack of a generally accepted complete CRRT 'set' have impeded implementation of the technique in clinical practice. Unresolved questions regarding dosage and assessment preclude evidence-based comparison in prospective, multicentre studies. For the moment, each institution has to develop a local working protocol. In clinical practice, detailed staff training and monitoring of possible metabolic disturbances for this complex intervention is essential.
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain therapy, University Hospital, Münster, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Lanckohr
authors.forename: Klaus
authors.initials: K
authors.lastname: Hahnenkamp
authors.forename: Matthias
authors.initials: M
authors.lastname: Boschin
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D019343:Citric Acid / Q000627:therapeutic use*; D003422:Critical Care; D006801:Humans; D017582:Renal Replacement Therapy
chemical_list: D000925:Anticoagulants; D019343:Citric Acid