Table 8.

Metabolic complications of citrate utilization with continuous RRT

ComplicationMechanismDiagnosisManagement
Citrate excessMetabolic conversion of citrate to bicarbonate resulting in excess bufferMetabolic alkalosisDecrease blood flow rate
Total Ca++/iCa++ <2.5Increase dialysate flow rate, or decrease buffer concentration in other CRRT solutions
Citrate toxicityDecreased metabolic conversion of citrate resulting in accumulation of citrate-calcium complexes in bloodAnion gap metabolic acidosisDecrease blood flow rate, or increase dialysate flow rate, or discontinue citrate
Total Ca++/iCa++ >2.5
Escalating Ca++ infusion rate
Citrate deficitMetabolic conversion of citrate to bicarbonate resulting in insufficient bufferMetabolic acidosisIncrease blood flow rate
Total Ca++/iCa++ <2.5Decrease dialysate flow rate
Increase buffer concentration in other CRRT solutions
  • Ca++, calcium; iCa++, ionized calcium; CRRT, continuous RRT.