Regional citrate anticoagulation for renal replacement therapies in patients with acute kidney injury: a position statement of the Work Group “Renal Replacement Therapies in Critically Ill Patients” of the Italian Society of Nephrology

Patients with acute kidney injury (AKI) on renal replacement therapy (RRT) are at increased risk for bleeding but usually require anticoagulation of the extracorporeal circuit, a key prerequisite for delivery of an adequate RRT dose. To this end, many anti-hemostatic strategies have been proposed, unfractionated heparin--with all of its significant drawbacks and complications--being the most common method used so far. In this clinical context, regional citrate anticoagulation (RCA) could represent the most promising strategy, and it has been endorsed by recent guidelines on AKI. The aim of this position statement is to critically review the current evidence on RCA for the extracorporeal circuit of RRT in patients with AKI, in order to provide suggestions for its application in clinical practice. To this purpose, the most relevant clinical studies and recent guidelines on AKI with special regard to anti-hemostatic strategies for RRT circuit maintenance have been reviewed and commented. Experts from the Working Group "Renal Replacement Therapies in Critically Ill Patients" of the Italian Society of Nephrology have prepared this position paper, which discusses the basic principles, advantages and drawbacks of RCA based on the available safety and efficacy data. Advice is given on how to use and monitor RCA in the different RRT modalities, in order to avoid complications while maximizing the delivery of the prescribed RRT dose.