Observational studyCritical care (London, England)2025
Clinical and biological profiles associated with the time of occurrence of citrate accumulation in patients receiving continuous renal replacement therapy.
Observational study in Critical care (London, England), 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers.
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Who cites it
12 citing papers in PubMed.
- Citrate accumulation during regional citrate anticoagulation for continuous renal replacement therapy: a narrative review.Renal failure · 2026Review
- Impact of post-filter ionized calcium target range on circuit survival and citrate-related complications in pediatric continuous kidney replacement therapy.Pediatric nephrology (Berlin, Germany) · 2026Article
- Systemic Citrate Toxicity During Regional Citrate Anticoagulation for Continuous Kidney Replacement Therapy.Journal of clinical medicine · 2026Review
- Reevaluating the 2.5 total-to-ionized calcium threshold during RCA-CKRT.Critical care (London, England) · 2026Article
- Ionized hypocalcemia prior to continuous veno-venous hemodialysis initiation: prevalence and consequences.BMC anesthesiology · 2026Article
- Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management.Critical care (London, England) · 2026Review
- Should we change our approach to detecting citrate accumulation in patients treated with CRRT with regional citrate?Critical care (London, England) · 2026Article
- Beyond static thresholds: the "citrate challenge" as a physiology-guided bedside framework.Critical care (London, England) · 2026Article
- Article
- Albumin-corrected tCa/iCa ratio: are we still diagnosing citrate accumulation or predicting mortality?Critical care (London, England) · 2026Article
- Challenging the citrate challenge: why we need global criteria to define citrate accumulation.Critical care (London, England) · 2026Article
- The "citrate challenge": mitigating the risk of citrate accumulation in high-risk patients.Critical care (London, England) · 2025Article
Corrections and comments
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Authors and funding
11 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundCitrate accumulation (CA) is a feared complication in critically ill patients undergoing regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT). This study aimed to describe the characteristics of patients presenting CA within a large cohort of unselected critically ill patients receiving RCA-CRRT depending on the time of occurrence of CA after CRRT initiation.
methodsThis retrospective, multicenter observational study performed in nine intensive care units (ICU) in Lyon, France, included patients treated with RCA-CRRT between January 2020 and January 2022. CA was defined by a total to ionized calcium ratio (tCa/iCa) ≥ 2.3 associated with hypocalcemia and metabolic acidosis.
resultsAmong 2080 patients, 76 (3.7%) developed CA: 69 (91%) experienced CA within 24 h after CRRT initiation (initial CA) and 7 (9%) after 24 h (late-onset CA). Only lactate levels at CRRT initiation differed between patients with initial CA and those with late-onset CA (10 mmol/l [4.6-16] vs 1.4 mmol/l [1-3.8], p = 0.006 respectively). In the initial CA group, 39 (57%) exhibited signs of CA within 6 h or less (immediate CA) and 30 (43%) showed signs of CA between 6 and 24 h. Over the first 24 h, patients with initial CA presented a marked increase in lactate levels, worsening norepinephrine requirements, persistent elevation of the tCa/iCa ratio, decrease in prothrombin time, and increase in transaminases. Patients with immediate CA showed higher lactate concentration and more severe metabolic acidosis at CRRT initiation compared to patients with early CA whereas other markers did not differ significantly between the two groups. The area under the Receiver Operating Characteristic curve of lactate and pH for predicting immediate citrate accumulation were 0.75 [0.62 - 0.87] and 0.74 [0.62 - 0.85] respectively, with optimal cutoff values of 10.6 mmol/L and 7.14 respectively. The ICU mortality rate among patients with CA was 97% compared to 55% in the whole cohort.
conclusionsCA is a rare phenomenon in patients under RCA-CRRT. Severe metabolic acidosis with hyperlactatemia at CRRT initiation is the most relevant marker to identify patients at risk of immediate CA and should encourage close monitoring of tCa/iCa ratio.
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