Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management
Review published in Critical care (London, England) (2026)
Abstract
BACKGROUND: Regional citrate anticoagulation (RCA) is recommended by guidelines over systemic heparinization for continuous renal replacement therapy (CRRT). However, its use in patients with impaired citrate metabolism poses specific challenges and standardized guidance for managing RCA-related metabolic complications remains lacking. METHODS: A modified Delphi study was conducted according to a predefined protocol and reported in adherence with the CREDES (Conducting and REporting of DElphi Studies) checklist. The international expert panel comprised 29 clinicians and researchers from Europe, United States and Canada, with recognized expertise in RCA for CRRT in critically ill patients. Three iterative survey rounds were conducted to obtain agreement with proposed statements. RESULTS: Twenty-three experts completed all Delphi rounds, achieving consensus on twenty-two statements. RCA was considered feasible in patients with liver dysfunction, severe shock, or hyperlactatemia, with close monitoring and citrate dosing adjustment. Citrate accumulation can be prevented and managed using a stepwise approach, focused on reducing citrate delivery and discontinuing RCA in cases of overt accumulation. Metabolic alkalosis and electrolyte disturbances were identified as relevant but manageable complications, underscoring the need for individualizing CRRT settings. CONCLUSION: These consensus statements support the use of RCA during CRRT in critically ill patients with impaired citrate metabolism and provide practical guidance for monitoring and management of metabolic complications. However they reflect expert opinion, especially for questions with limited data and low-level evidence.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Regional citrate anticoagulation (RCA) is recommended by guidelines over systemic heparinization for continuous renal replacement therapy (CRRT). However, its use in patients with impaired citrate metabolism poses specific challenges and standardized guidance for managing RCA-related metabolic complications remains lacking.
Why This Matters for Hirudotherapy
This modified Delphi consensus convened an international panel (23 experts completing all rounds) and reached agreement on 22 statements about regional citrate anticoagulation (RCA) for continuous renal replacement therapy, concluding RCA is feasible even with impaired citrate metabolism given close monitoring and dose adjustment, and offering practical guidance on citrate accumulation and metabolic alkalosis. The ASH relevance is tangential: citrate is an extracorporeal-circuit anticoagulant with a mechanism entirely unrelated to the leech secretome, so this document is useful only as a reminder that 'anticoagulation' spans many distinct mechanisms and that medicinal-leech-derived agents address a different (local, antithrombin/factor-targeting) niche. Honest caveat: this is expert-opinion consensus, not experimental data, explicitly acknowledging low-level evidence for several statements; it has no connection to leeches or hirudotherapy and should be cited only to delineate, not support, the leech-secretome story.
Citation
Metabolic complications of citrate anticoagulation in continuous renal replacement therapy (crrt): a delphi consensus on indications, monitoring and management.
Jacobs R et al. · Critical care (London, England), 2026
Added to ASH library: May 28, 2026 · Site last updated: June 18, 2026