CRRT — circuit clotting and the citrate complications

A CICM SAQ on the CRRT troubleshooting — the recurrent circuit clotting (the anticoagulation, the blood flow, the filtration fraction, the access) and the citrate accumulation (the rising total-to-ionized ratio, the metabolic acidosis in the liver failure).

Prompt

A patient on the CVVHDF with the regional citrate anticoagulation has three circuit changes in 24 hours and a rising total-to-ionized calcium ratio. Discuss the troubleshooting and the citrate management.

Question

References8Show

[1]Dai T, Shah A, Chong CC, et al. Evolution of continuous renal replacement therapy scenarios and the rise of anticoagulant-free continuous veno-venous hemodiafiltration Curr Opin Nephrol Hypertens, 2026.PMID 41263052
[2]Wang F, Lin L, Li P, Huang X, et al. Saline flushing to prevent circuit clotting during CRRT without anticoagulant: a randomized controlled study BMC Nurs, 2025.PMID 40855484
[3]Schultheiß C, Saugel B, Phillip V, Thies P, et al. Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study Crit Care, 2012.PMID 22913794
[4]Bianchi NA, Altarelli M, Schneider AG Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study Blood Purif, 2020.PMID 32126564
[5]Assefi M, Leurent A, Blanchard F, Quemeneur C, et al. Impact of increasing post-filter ionized calcium target on filter lifespan in renal replacement therapy with regional citrate anticoagulation: A before-and-after study J Crit Care, 2023.PMID 37379797
[6]Bellomo R, Cass A, Cole L, Finfer S, et al. Intensity of continuous renal-replacement therapy in critically ill patients N Engl J Med, 2009.PMID 19846848
[7]Parienti JJ, Mongardon N, Mégarbane B, Mira JP, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site N Engl J Med, 2015.PMID 26398070
[8]Oudemans-van Straaten HM, Ostermann M Citrate anticoagulation for CRRT: don't always trust the postfilter iCa results! Crit Care, 2015.PMID 26635277

CRRT — circuit clotting and the citrate complications

Question

References8Show

[1]Dai T, Shah A, Chong CC, et al. Evolution of continuous renal replacement therapy scenarios and the rise of anticoagulant-free continuous veno-venous hemodiafiltration Curr Opin Nephrol Hypertens, 2026.PMID 41263052
[2]Wang F, Lin L, Li P, Huang X, et al. Saline flushing to prevent circuit clotting during CRRT without anticoagulant: a randomized controlled study BMC Nurs, 2025.PMID 40855484
[3]Schultheiß C, Saugel B, Phillip V, Thies P, et al. Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study Crit Care, 2012.PMID 22913794
[4]Bianchi NA, Altarelli M, Schneider AG Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study Blood Purif, 2020.PMID 32126564
[5]Assefi M, Leurent A, Blanchard F, Quemeneur C, et al. Impact of increasing post-filter ionized calcium target on filter lifespan in renal replacement therapy with regional citrate anticoagulation: A before-and-after study J Crit Care, 2023.PMID 37379797
[6]Bellomo R, Cass A, Cole L, Finfer S, et al. Intensity of continuous renal-replacement therapy in critically ill patients N Engl J Med, 2009.PMID 19846848
[7]Parienti JJ, Mongardon N, Mégarbane B, Mira JP, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site N Engl J Med, 2015.PMID 26398070
[8]Oudemans-van Straaten HM, Ostermann M Citrate anticoagulation for CRRT: don't always trust the postfilter iCa results! Crit Care, 2015.PMID 26635277