Table 3 Recommendations to counter systemic effects of RCA in CRRT

Citrate accumulation/overload (T/iCa)

Patient selection, limit net citrate dose (blood flow dependent)

 < 6 h depending on metabolic status

Care with patients in shock/liver failure

[4, 5, 61]

Increased iPTH

Ensure adequate systemic iCa before initiation of citrate CRRT, maintain systemic iCa > 1.0 mmol/l

Low iCa seen < 4 h after initiation

[25, 28, 32]

Negative calcium balance

Limit net citrate dose (blood flow dependent) early sampling and supplementation; calcium compensation always at 100% on CRRT machine

 < 4 h

Citrate dose-dependent loss in effluent; in diffusive modalities blood flow is lower; hypercalcemia of immobilization may mask negative calcium balance in longer term

[4, 12, 25,26,27,28]

Negative magnesium balance

Limit net citrate dose (blood flow dependent), early sampling and supplementation, use of substitution fluids with higher magnesium concentration

 < 12 h (dependent on initial value)

Citrate dose-dependent loss in effluent, in diffusive modalities blood flow is lower

[4, 12, 28, 38,39,40]

Negative phosphate balance

Early sampling and supplementation, use of substitution fluids with higher phosphate concentration

 < 12 h (dependent on initial value)

Monitor for possible calcium phosphate precipitation at the site of calcium reinjection point when using higher phosphate-containing fluids

[47, 50,51,52,53,54,55,56,57,58,59,60]