Regional Citrate Anticoagulation in CRRT: Successes, Pitfalls, and Sustainability from a Long-Term Single-Center Experience

<b>Background:</b> Regional citrate anticoagulation (RCA) is the recommended first-line strategy for continuous renal replacement therapy (CRRT), yet global implementation remains inconsistent. We reviewed our extensive single-center experience to provide a real-life evaluation of RCA feasibility, limitations, and environmental sustainability. <b>Methods</b>: We retrospectively analyzed RCA treatments performed in our center from 2012 to 2022. Technical performance was assessed by circuit patency and failure timing. Environmental impact was evaluated by simulating filter consumption and hazardous waste production compared to a projected strategy using unfractionated heparin (UFH). <b>Results</b>: RCA utilization grew progressively, reaching 98% of all treatments. The technique showed an 80.2% success rate and a robust safety profile, demonstrating excellent feasibility and efficacy in clinical practice. However, among circuits intended for 72 h survival, over one-third failed prematurely; segmented regression confirmed a critical high-risk period within the first 24 h, with a significantly higher rate of circuit loss compared to the subsequent period (<i>p</i> < 0.05). In our simulation, RCA adoption saved over 1000 filters, preventing the emission of approximately 12 tons of CO₂ equivalent. <b>Conclusions</b>: RCA is a safe, effective, and environmentally appealing method of CRRT. However, significant room for improvement remains; refining the technique to increase circuit success rates is essential to optimize clinical efficiency and further minimize the ecological footprint of acute renal care.