• Harin Rhee, Brendan Berenger, Ravindra L Mehta, and Etienne Macedo.
• Department of Medicine, University of California, San Diego, La Jolla, California; Department of Internal Medicine, Pusan National University School of Medicine, Pusan, Republic of Korea.
• Am. J. Kidney Dis. 2021 Oct 1; 78 (4): 550-559.e1.

ObjectiveRegional citrate anticoagulation (RCA) is the preferred anticoagulation method for continuous kidney replacement therapy (CKRT) recommended by KDIGO. Limited availability of calcium-free solutions often imposes challenges to the implementation of RCA for CKRT (RCA-CKRT). The principal purpose of this study was to characterize the outcomes of RCA-CKRT using calcium-containing solutions.Study DesignRetrospective cohort study.Setting & ParticipantsWe evaluated the safety and efficacy of RCA-CKRT with calcium-containing dialysate and replacement fluid used for 128 patients. A total of 571 filters and 1,227 days of CKRT were analyzed.ExposuresLiver disease, sepsis in the absence of liver disease, and sepsis with liver disease.OutcomesFilter life and metabolic complications per 100 CKRT days.Analytical ApproachLinear mixed-effects model and generalized linear mixed-effects models.ResultsThe majority of patients were male (91; 71.1%), 32 (25%) had liver disease, and 29 (22.7%) had sepsis without liver disease. Median filter life was 50.0 (interquartile range, 22.0-118.0) hours, with a maximum of 322 hours, and was significantly lower (33.5 [interquartile range, 17.5-60.5] h) in patients with liver disease. Calcium-containing replacement solutions were used in 41.6% of all CKRT hours and reduced intravenous calcium requirements by 31.7%. Hypocalcemia (ionized calcium<0.85mmol/L) and hypercalcemia (total calcium>10.6mg/dL) were observed in 6.0 and 6.7 per 100 CKRT days, respectively. Citrate accumulation was observed in 13.3% of all patients and was associated with metabolic acidosis in 3.9%, which was not significantly different in patients with liver disease (9.3%; P = 0.2).LimitationsLack of control groups that used calcium-free dialysate and replacement solutions with RCA-CKRT. Possible overestimation of filter life from incomplete data on cause of filter failure.ConclusionsOur study suggests that RCA-CKRT with calcium-containing solutions is feasible and safe in critically ill patients, including those with sepsis and liver disease.Copyright © 2021 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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