LAUSR

BACKGROUND Continuous renal replacement therapy (CRRT) with regional citrate anticoagulation (RCA) in newborns and infants is challenging and accumulation of citrate can occur. There are only a few studies reporting detailed data on RCA. We aimed to analyze RCA-CRRT at our institution with focus on citrate accumulation. PATIENTS AND METHODS Critically ill newborns and infants up to 11 kg of body weight (BW), treated with RCA-CRRT in 2011-2016 period were included in this retrospective observational study. Prismaflex(R) and Multifiltrate-CiCa(R) dialysis monitors were used with either automated or manual RCA. Data was collected regarding circuit lifetime, parameters of RCA, markers of citrate accumulation (total/ionized calcium ratio > 2.5) and metabolic complications. RESULTS We included 10 children with mean age 2.6±3.8 months and BW of 4.6±2.7 kg. In-hospital mortality was 60%. RCA-CRRT parameters were: blood flow 46±9 ml/min (12±5 ml/min/kg BW), citrate dose 2.8±0.6 mmol/l of blood resulting in estimated citrate load to the patient of 1.7±0.8 mmol/h/kg BW. In total, 57 dialysis circuits were used with mean filter lifetime of 39±29 h. Citrate accumulation (total/ionized calcium ratio > 2.5) was observed in 7/10 patients and in 14/57 (25%) of circuits; those circuits were performed in children with lower age and BW, had higher relative blood flow and citrate load, while citrate dose was similar. When citrate load to the patient was used to predict citrate accumulation, AUC under the ROC curve was 0.78 and 1.7 mmol/h/kg BW was considered the optimal cut-off value (sensitivity 71% and specificity 72%). CONCLUSIONS CRRT with RCA using equipment, developed for adult population, is feasible in newborns and infants. Signs of citrate accumulation developed relatively often. To prevent it, we suggest avoiding citrate loads above 1.7 mmol/h/kg BW, which can best be achieved by keeping blood flow below 9 ml/min/kg BW.