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Highly Accessed Open Badges Commentary

Regional citrate anticoagulation in patients with liver failure - time for a rethink?

Sameer Patel1 and Julia Wendon2*

Author Affiliations

1 King's College Hospital, Denmark Hill, London SE5 9RS, UK

2 Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK

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Critical Care 2012, 16:153  doi:10.1186/cc11492

See related research by Schultheiss et al.,

Published: 17 September 2012


Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) has become increasingly attractive in recent years due to its favourable low bleeding risk profile. Its use in liver failure, however, has been limited due to the risk of citrate accumulation and toxicity. In the previous issue of Critical Care, Schultheiss and colleagues look at CRRT using RCA in liver failure patients. They demonstrate that citrate accumulation can be predicted using the total calcium (Catot) to ionised calcium (Caion) ratio (Catot/Caion), and determine that despite the occurrence of significant citrate accumulation, the effects of citrate accumulation are not as severe as might have been expected. This study raises interesting prospects with regard to RCA use in liver failure, and we postulate that citrate may have a role as a prognostic marker of metabolic capacity much as in the way of lactate and methacetin. However, further studies are warranted, in particular examining its application in subgroups of liver failure (chronic, acute, hyperacute and subacute), before its use becomes commonplace.