Complications of regional citrate anticoagulation: accumulation or overload?

Crit Care. 2017 Nov 19;21(1):281. doi: 10.1186/s13054-017-1880-1.


Regional citrate anticoagulation (RCA) is now recommended over systemic heparin for continuous renal replacement therapy in patients without contraindications. Its use is likely to increase throughout the world. However, in the absence of citrate blood level monitoring, the diagnosis of citrate accumulation, the most feared complication of RCA, remains relatively complex. It is therefore commonly mistaken with other conditions. This review aims at providing clarifications on RCA-associated acid-base disturbances and their management at the bedside. In particular, the authors wish to propose a clear distinction between citrate accumulation and net citrate overload.

Keywords: Acute kidney injury; Citrate accumulation; Complications of therapy; Continuous renal replacement therapy; Metabolic alkalosis; Regional citrate anticoagulation.

MeSH terms

  • Acid-Base Equilibrium / physiology
  • Acute Kidney Injury / drug therapy
  • Anticoagulants / adverse effects
  • Anticoagulants / therapeutic use
  • Citric Acid / adverse effects*
  • Citric Acid / analysis
  • Citric Acid / therapeutic use
  • Humans
  • Intensive Care Units / organization & administration
  • Renal Replacement Therapy / instrumentation
  • Renal Replacement Therapy / methods*
  • Renal Replacement Therapy / trends


  • Anticoagulants
  • Citric Acid