Pediatric Nephrology

, Volume 29, Issue 9, pp 1625–1631 | Cite as

Regional citrate anticoagulation for pediatric CRRT using integrated citrate software and physiological sodium concentration solutions

  • Jean-Michel LietEmail author
  • Emma Allain-Launay
  • Bénédicte Gaillard-LeRoux
  • François Barrière
  • Alexis Chenouard
  • Jean-Marc Dejode
  • Nicolas Joram
Original Article



In continuous renal replacement therapy (CRRT), regional citrate anticoagulation offers an attractive alternative to heparinization, especially for children with a high bleeding risk.


We report on a new management approach to CRRT using integrated citrate software and physiological sodium concentration solutions. Convective filtration was performed with pre-filter citrate anticoagulation using an 18 mmol/L citrate solution and a post-filter replacement fluid. The citrate flow rate was automatically adjusted to the blood flow rate by means of integrated citrate software. Similarly, calcium was automatically infused into children to maintain their blood calcium levels within normal range.


Eleven CRRT sessions were performed (330 h) in seven critically ill children aged 3–15 years (extreme values 15–66 kg). Disease categories included sepsis with multiorgan dysfunction (n = 2) and hemolytic uremic syndrome (n = 5). Median effluent dose was 2.1  (extreme values 1.7–3.3) L/h/1.73 m2. No session had to be stopped because of metabolic complications. Calcium levels, both in the circuits and in the circulating blood of the children, remained stable and secure.


Regional citrate anticoagulation can be used in children with a body weight of >15 kg using integrated citrate software and commercially available solutions with physiological sodium concentrations in a safe, effective and convenient procedure.


Continuous venovenous hemofiltration Children Citrate anticoagulation Acute kidney injury Continuous renal replacement therapy Pediatric intensive care 



We would especially like to thank the nurses who were involved in this project (Hemofiltration Workgroup).


  1. 1.
    Wu MY, Hsu YH, Bai CH, Lin YF, Wu CH, Tam KW (2012) Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials. Am J Kidney Dis 59:810–818PubMedCrossRefGoogle Scholar
  2. 2.
    Oudemans-van Straaten HM, Wester JP, de Pont AC, Schetz MR (2006) Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based? Intensive Care Med 32:188–202PubMedCrossRefGoogle Scholar
  3. 3.
    Monchi M, Berghmans D, Ledoux D, Canivet JL, Dubois B, Damas P (2004) Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: a prospective randomized study. Intensive Care Med 30:260–265PubMedCrossRefGoogle Scholar
  4. 4.
    Zappitelli M, Juarez M, Castillo L, Coss-Bu J, Goldstein SL (2009) Continuous renal replacement therapy amino acid, trace metal and folate clearance in critically ill children. Intensive Care Med 35:698–706PubMedCrossRefGoogle Scholar
  5. 5.
    Symons JM, Chua AN, Somers MJ, Baum MA, Bunchman TE, Benfield MR, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Hackbarth R, Alexander SR, Mahan J, McBryde KD, Goldstein SL (2007) Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2:732–738PubMedCrossRefGoogle Scholar
  6. 6.
    Elhanan N, Skippen P, Nuthall G, Krahn G, Seear M (2004) Citrate anticoagulation in pediatric continuous venovenous hemofiltration. Pediatr Nephrol 19:208–212PubMedCrossRefGoogle Scholar
  7. 7.
    Chadha V, Garg U, Warady BA, Alon US (2002) Citrate clearance in children receiving continuous venovenous renal replacement therapy. Pediatr Nephrol 17:819–824PubMedCrossRefGoogle Scholar
  8. 8.
    Bunchman TE, Maxvold NJ, Brophy PD (2003) Pediatric convective hemofiltration: normocarb replacement fluid and citrate anticoagulation. Am J Kidney Dis 42:1248–1252PubMedCrossRefGoogle Scholar
  9. 9.
    Askenazi DJ, Goldstein SL, Koralkar R, Fortenberry J, Baum M, Hackbarth R, Blowey D, Bunchman TE, Brophy PD, Symons J, Chua A, Flores F, Somers MJ (2013) Continuous renal replacement therapy for children </=10 kg: a report from the prospective pediatric continuous renal replacement therapy registry. J Pediatr 162(587–592):e583Google Scholar
  10. 10.
    Strazdins V, Watson AR, Harvey B (2004) Renal replacement therapy for acute renal failure in children: European guidelines. Pediatr Nephrol 19:199–207PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Ronco C, Ricci Z (2008) Renal replacement therapies: physiological review. Intensive Care Med 34:2139–2146PubMedCrossRefGoogle Scholar
  12. 12.
    Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL (2007) Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int 71:1028–1035PubMedCrossRefGoogle Scholar
  13. 13.
    Davenport A (2012) Alternatives to standard unfractionated heparin for pediatric hemodialysis treatments. Pediatr Nephrol 27:1869–1879PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Maclaren G, Butt W (2009) Controversies in paediatric continuous renal replacement therapy. Intensive Care Med 35:596–602PubMedCrossRefGoogle Scholar
  15. 15.
    Morabito S, Pistolesi V, Tritapepe L, Zeppilli L, Polistena F, Strampelli E, Pierucci A (2012) Regional citrate anticoagulation in cardiac surgery patients at high risk of bleeding: a continuous veno-venous hemofiltration protocol with a low concentration citrate solution. Crit Care 16:R111PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Maxvold NJ, Smoyer WE, Custer JR, Bunchman TE (2000) Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis. Crit Care Med 28:1161–1165PubMedCrossRefGoogle Scholar
  17. 17.
    Santiago MJ, Lopez-Herce J, Urbano J, Solana MJ, del Castillo J, Ballestero Y, Botran M, Bellon JM (2010) Clinical course and mortality risk factors in critically ill children requiring continuous renal replacement therapy. Intensive Care Med 36:843–849PubMedCrossRefGoogle Scholar
  18. 18.
    Balogun RA, Turgut F, Caldwell S, Abdel-Rahman EM (2012) Regional citrate anticoagulation in critically ill patients with liver and kidney failure. J Nephrol 25:113–119PubMedCrossRefGoogle Scholar
  19. 19.
    Schultheiss C, Saugel B, Phillip V, Thies P, Noe S, Mayr U, Haller B, Einwachter H, Schmid RM, Huber W (2012) Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study. Crit Care 16:R162PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Brophy PD, Somers MJ, Baum MA, Symons JM, McAfee N, Fortenberry JD, Rogers K, Barnett J, Blowey D, Baker C, Bunchman TE, Goldstein SL (2005) Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant 20:1416–1421PubMedCrossRefGoogle Scholar
  21. 21.
    Bugg NC, Jones JA (1998) Hypophosphataemia. Pathophysiology, effects and management on the intensive care unit. Anaesthesia 53:895–902PubMedCrossRefGoogle Scholar
  22. 22.
    Santiago MJ, Lopez-Herce J, Urbano J, Bellon JM, del Castillo J, Carrillo A (2009) Hypophosphatemia and phosphate supplementation during continuous renal replacement therapy in children. Kidney Int 75:312–316PubMedCrossRefGoogle Scholar
  23. 23.
    Hanley JA, Lippman-Hand A (1983) If nothing goes wrong, is everything all right? interpreting zero numerators. JAMA 249:1743–1745PubMedCrossRefGoogle Scholar
  24. 24.
    Sutherland SM, Alexander SR (2007) Continuous renal replacement therapy in children. Pediatr Nephrol 27:2007–2016CrossRefGoogle Scholar
  25. 25.
    Parakininkas D, Greenbaum LA (2004) Comparison of solute clearance in three modes of continuous renal replacement therapy. Pediatr Crit Care Med 5:269–274PubMedCrossRefGoogle Scholar
  26. 26.
    Dorval M, Madore F, Courteau S, Leblanc M (2003) A novel citrate anticoagulation regimen for continuous venovenous hemodiafiltration. Intensive Care Med 29:1186–1189PubMedCrossRefGoogle Scholar
  27. 27.
    Gabutti L, Marone C, Colucci G, Duchini F, Schonholzer C (2002) Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge. Intensive Care Med 28:1419–1425PubMedCrossRefGoogle Scholar
  28. 28.
    Slater A, Shann F, Pearson G (2003) PIM2: a revised version of the paediatric index of mortality. Intensive Care Med 29:278–285PubMedGoogle Scholar

Copyright information

© IPNA 2014

Authors and Affiliations

  • Jean-Michel Liet
    • 1
    Email author
  • Emma Allain-Launay
    • 2
  • Bénédicte Gaillard-LeRoux
    • 1
  • François Barrière
    • 1
  • Alexis Chenouard
    • 1
  • Jean-Marc Dejode
    • 1
  • Nicolas Joram
    • 1
  1. 1. Unité de Réanimation Pédiatrique, Pôle Femme-Enfant-AdolescentCentre hospitalier universitaire (CHU) de NantesNantesFrance
  2. 2.Unité de Néphrologie Pédiatrique, Clinique Médicale Pédiatrique, Pôle Femme-Enfant-AdolescentCHU of NantesNantesFrance

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