Abstract: SA-PO0038
Combined Carbon Dioxide (CO2) Removal and CRRT Using Regional Citrate Anticoagulation in a Critically Ill Patient: A Case Report
Session Information
- AKI: Novel Patient Populations and Case Reports
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 101 AKI: Epidemiology, Risk Factors, and Prevention
Authors
- Eick, Renato George, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Sartori Pacini, Gabriel, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Vizioli, Luis Henrique, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Melere, Camila Mosmann, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Ramos, Marcelo Carpena, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Schuchmann, Renata Asnis, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
- Stein, Anna Cristina, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Kalil, Milton, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- André, Mauricio Lutzky, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Saitovich, David, Associacao Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
Introduction
Regional citrate anticoagulation (RCA) is widely used in continuous renal replacement therapy (CRRT) due to its effectiveness in maintaining circuit patency and its favorable safety profile. However, when CRRT is combined with extracorporeal carbon dioxide removal (ECCO2R), current guidelines tend to favor systemic anticoagulation with heparin due to the risk of metabolic alkalosis, hypernatremia and disturbances in calcium homeostasis associated with the higher citrate doses required. These limitations underscore the need for further research into the safety and efficacy of citrate in this context
Case Description
A 54-year-old male with a medical history of HIV, type 2 diabetes mellitus, obesity, and hypertension was admitted to the intensive care unit (ICU) with pulmonary septic shock secondary to Pneumocystis infection. He developed hypercapnic respiratory failure refractory to conventional mechanical ventilation, although without severe hypoxemia to warrant extracorporeal membrane oxygenation (ECMO). The patient also progressed to acute kidney injury (AKI), classified as KDIGO stage 3. Given the combined respiratory and renal dysfunction, integrated extracorporeal support was initiated with continuous venovenous hemodiafiltration (CVVHDF) and ECCO2R, using the Baxter PrismaLung® system. Final dialysis solutions contained a sodium concentration of 105 mEq/L and no added bicarbonate. Citrate dosing was guided by protocolized targets with rigorous monitoring of pre- and post-filter ionized calcium, as well as systemic calcium levels, to ensure safety and efficacy. The total filter runtime was approximately 245 hours. The patient tolerated the therapy well, with effective CO2 clearance and adequate metabolic control throughout the treatment period. Additionally, no bleeding events or clinically significant or persistent metabolic disturbances were observed
Discussion
This case demonstrates that RCA is feasible in combined CRRT–ECCO2R therapy. Despite potential risks with higher citrate doses, these can be managed with strict protocols and monitoring. Further research is needed to assess the broader safety, efficacy, and cost-effectiveness of RCA in this context.