Kidney Week

Abstract: SA-PO1092

Regional Citrate Anticoagulation Is Safe in Severe Liver Dysfunction During CRRT and Improves Circuit Performance

Session Information

• Kidney Replacement Therapy and Care Delivery Innovations
  October 24, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Estrella, Luis A., Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Luis A. Estrella, MD

• Esteban-Prado, Alejandro, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Alejandro Esteban-Prado, MD

• Mercado Hernández, Yazmin Alejandra, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Yazmin Alejandra Mercado Hernández, MD

• Carreón Tapia, Daira Magdalena, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Daira Magdalena Carreón Tapia, MEd

• Ruvalcaba Cristerna, Luisa Svetlana, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Luisa Svetlana Ruvalcaba Cristerna, DrMed

• Del Toro-Cisneros, Noemi, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Noemi Del Toro-Cisneros, MD

• Rincon-Pedrero, Rodolfo, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Rodolfo Rincon-Pedrero, MD

• Vega, Olynka, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, CDMX, Mexico

Olynka Vega, MD, MS

Background

Regional citrate anticoagulation (RCA) is the preferred anticoagulation strategy for continuous renal replacement therapy (CRRT) due to superior circuit performance and lower bleeding risk. However, patients with severe liver dysfunction are frequently excluded from RCA because of concerns regarding impaired citrate metabolism and citrate accumulation. Evidence supporting RCA safety in this high-risk population remains limited.

Methods

We conducted a single-center retrospective cohort study including patients with severe liver dysfunction (acute liver failure, acute-on-chronic liver failure, or post-liver transplantation dysfunction) requiring CRRT. Patients receiving RCA were compared with those managed without citrate anticoagulation. The primary safety outcome was incidence of citrate or accumulation. Secondary outcomes included circuit clotting, premature filter loss, filter lifespan, transmembrane pressure, and filter utilization.

Results

Sixty-seven critically ill patients with severe liver dysfunction undergoing CRRT were included (RCA n=39; and non-RCA n=28). Despite advanced liver disease severity (mean MELD 30+12), clinically significant citrate overload was infrequent, occurring in 6 patients (15.8%) and resolved after protocol adjustments, while citrate accumulation occured only in 1 patient (2.5%). No deaths were attributable to RCA-related metabolic complications. RCA markedly reduced circuit clotting (10.3% vs. 51.9%, p<0.001), premature filter loss (12.8% vs 57.1%, p<0.001), number of filters used per patient (median 1 vs 2, p<0.001). Kaplan-Meier analysis demonstrated significantly improved filter survival with RCA (log-rank p<0.001).

Conclusion

RCA was safe and associated with substantially improved circuit performance. True citrate accumulation was rare despite advance hepatic dysfunction. These findings support RCA as a feasible and effective anticoagulation strategy in a population historically considered at high risk for citrate toxicity.