everytime citrat, heparin only when you need another full antitrombotic therapy

I agree in the better profile of citrate as anticoagulant and even in the posible better safety profile but I disagree with the position of the KDIGO statement about using it as first option (evidence is not so strong...). Protocols for citrate are improving but are yet demanding and the potential risk of an error must be taken into acount, so we must admit that right now they are not error-proof. Regarding cost, in those cases when heparine is working the cost is clearly lower for this option. Low dose heparine (below 7 u/Kg) is safe in terms of haemorrage and is as valid a first choice as citrate. As a fact we are now using citrate as second step for those cases with contraindication to heparine or with a high rate of filter clotting and believe this is the more eficient aproach while assuring patient safety (our first concern).

I agree with Dr Herrera-Gutierrez. The protocols for citrate use are a bit complex and one needs to be careful of complications. Heparin is still cheaper and very effective in most patients (with or without AKI). Citrate can be used for difficult situations or where heparin is contraindicated. On the other hand, the more one uses citrate, better one gets at it! So the choice is yours. Hope this is useful

The use of citrate is equally effective and probably safer than heparin in special situations. Most centers have started using Citrate more often, but there is a lack of quality studies to compare citrate and heparin side by side especially in pediatric population. There is a recent review article in PCCM by Davis TK et al, which covers a lot of common concern of citrate regional anticoagulation. I hope this helpful. Pediatr Crit Care Med. 2014 Jun;15(5):471-85. doi: 10.1097/PCC.0000000000000148

Thank you for your kind input, this information and the suggestions you've made are very helpful. There is much in the way of studying to be undertaken with positive results being published before all sites turn away from Heparin in favour of citrate.

After 15 years of using citrate I must state that RCA IS CHEAPER THAN HEPARIN due to reduced circuit costs and particularly if you apply a calcium free lactate buffered fluid. This calculation does not include expenses for bleeding complications in heparin not mentioning medico-ethical issues to expose someone a bleeding risk on top of his criticall illness.

References:

1.) Balik M, Zakharchenko M, Otahal M, et al: Quantification of systemic dose of substrates for intermediate metabolism during citrate anticoagulation of continuous renal replacement therapy. Blood Purif 2012, 33: 80-87.

2.) Balik M, Zakharchenko M, Leden P, et al.: Bioenergetic gain of citrate anticoagulated continuous hemodiafiltration-a comparison between 2 citrate modalities and unfractionated heparin. J Crit Care 2013, 28(1):87-95.

3.) Balik M, Zakharchenko M, Matejovic M: Citrate anticoagulation of renal replacement therapy: Beyond filter life and patient´s safety. Yearbook of Intensive Care Medicine, Springer Verlag, March 2013, pp. 741-754.

4.) Balik M, Zakharchenko M, Leden P, et al: Tolerance and metabolic effects of a novel lactate buffered dialysis and substitution fluid for citrate anticoagulated continuous renal replacement therapy: Intensive Care Med 2013, 39(S2): 377 (abstract)

Hi Martin, thank you for your input. So many people are promoting the use of citrate through their experiences with it. Yet there are still those that feel it's use in dialysis is unreliable due to it's complicatory factors with protocols being complexed. As such placing citrate as a second option if heparin fails or is contraindicated. Only in one's exposure to this substance and understanding it's beneficial properties, with the control of potential side effects to our patients on ICU, can we truely say 'Yes' this is the product of choice for me, as you seem to have done. Thank you

We have been using citrate (first, homemade concentration of 30%) for more than 10 years (right now citrate 4%for compliance with european regulations purposes) with efficacy and security, provided nurses and junior doctors receive prior teaching. Heparin systemic administration is parallelled only in specific cases (ECMO..).