Diluted Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy in Pediatric Patients: A Systematic Review and Suggested Practice Points

Introduction: Continuous renal replacement therapy (CRRT) is increasingly used in critical pediatric patients with acute kidney injury (AKI). The choice of anticoagulant is vital to minimize circuit clotting and bleeding complications. Regional citrate anticoagulation (RCA) is preferred for its safety profile, particularly in critically ill pediatric patients who are susceptible to bleeding. Methods: A comprehensive literature search was conducted using PubMed, Google Scholar, and Cochrane databases following PRISMA guidelines. Keywords included "diluted citrate," "regional citrate anticoagulation," "continuous renal replacement therapy," "pediatrics," and "adverse effects." Studies were included if they involved neonates and pediatric patients, reported citrate concentration, and safety and efficacy outcomes of RCA in CRRT. Data were extracted on study characteristics, citrate concentration, circuit lifespan, metabolic and electrolyte disturbances, and other adverse effects. Results: A total of 16 studies met the inclusion criteria. RCA was associated with fewer clotting events and a longer median circuit life compared to heparin. However, complications such as metabolic alkalosis, hypocalcemia, and hypernatremia were noted. In our single-center experience, dilute citrate anticoagulation was used in 16 pediatric patients undergoing CRRT, showing promising results with reduced clotting and prolonged circuit life. The modified pediatric citrate protocol presented aims to address complications by using a diluted citrate solution. Conclusions: RCA is effective in prolonging circuit life and reducing clotting in pediatric CRRT. The modified pediatric citrate protocol presents a safer alternative by reducing the risk of metabolic and electrolyte disturbances. Ongoing monitoring of calcium and electrolyte levels is essential to mitigate potential complications. This protocol may standardize RCA use in pediatric CRRT, improving safety and outcomes for critically ill children with AKI. (c) 2025 S. Karger AG, Basel