Monitoring and dose adjustment of regional citrate anticoagulation for continuous renal replacement therapy

PURPOSE OF REVIEW: Regional citrate anticoagulation (RCA) is the preferred anticoagulation strategy for many patients receiving continuous renal replacement therapy (CRRT). Safe implementation requires a coordinated prescription integrating citrate delivery, citrate removal within the extracorporeal circuit, individualized calcium replacement, CRRT fluid composition, and structured biochemical monitoring. This review summarizes practical approaches to RCA prescription, monitoring, and dose adjustment, emphasizing recent advances in citrate kinetics, calcium homeostasis, impaired citrate metabolism, metabolic complications, and systems-based safety. RECENT FINDINGS: Randomized trials and meta-analyses continue to demonstrate that RCA prolongs circuit life and reduces bleeding compared with systemic heparin anticoagulation, although a mortality benefit has not been demonstrated. Recent studies have refined understanding of citrate dose, systemic citrate load, first-pass citrate extraction, individualized calcium replacement based on anticipated effluent calcium losses, and recognition of impaired citrate metabolism. They also support baseline ionized calcium assessment before CRRT initiation, integration of lactate trends into assessment of citrate metabolism, individualized CRRT fluid selection, and distinguishing true citrate accumulation from other metabolic effects of RCA. SUMMARY: RCA is most effectively managed as an integrated CRRT prescription in which citrate delivery and removal, individualized calcium replacement, CRRT fluid composition, and operational parameters are coordinated to optimize circuit anticoagulation while maintaining electrolyte and acid-base homeostasis. Prescription adjustment should focus on four recurring clinical scenarios: inadequate circuit anticoagulation, negative calcium balance, excessive bicarbonate generation from citrate metabolism, and impaired citrate metabolism. Standardized protocols, structured monitoring, staff training, and workflow integration remain central to safe RCA implementation.