Metabolic and coagulation effects of citrate: down to the last detail!

The recently published Liver Citrate Anticoagulation Threshold (L-CAT) trial convincingly showed that continuous renal replacement therapy with regional citrate anticoagulation (CRRT-RCA) was safe and effective in patients with severely impaired liver function. Striking findings were a relatively low incidence of acid–base disorders and a markedly long 72-h filter survival [1]. Nonetheless, we would like to comment on two important metabolic issues. First, the low (2 %) incidence of severe metabolic alkalosis, defined as a pH >7.55, is probably highly underestimated. Indeed, we recently evaluated the occurrence of metabolic alkalosis defined either as a pH >7.50 or as an apparent strong ion difference (SIDa) >45 mmol/L according to the Stewart-Figge methodology [2] in patients undergoing CRRT-RCA