{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T12:26:24Z","timestamp":1789820784797,"version":"4.0.1"},"reference-count":16,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"2","funder":[{"DOI":"10.13039\/100000062","name":"HHS | NIH | National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"crossref","award":["5T32DK007378-40"],"award-info":[{"award-number":["5T32DK007378-40"]}],"id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["Kidney360"],"published-print":{"date-parts":[[2021,2]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Regional citrate anticoagulation (RCA) is not recommended in patients with shock or severe liver failure. We designed a protocol with personalized precalculated flow settings for patients with absent citrate metabolism that abrogates risk of citrate toxicity, and maintains neutral continuous KRT (CKRT) circuit calcium mass balance and normal systemic ionized calcium levels.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A single-center prospective cohort study of patients in five adult intensive care units triaged to the CVVHDF-RCA \u201cShock\u201d protocol.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Of 31 patients included in the study, 30 (97%) had AKI, 16 (52%) had acute liver failure, and five (16%) had cirrhosis at the start of CKRT. The median lactate was 5 mmol\/L (interquartile range [IQR], 3.2\u201310.7), AST 822 U\/L (IQR, 122\u20132950), ALT 352 U\/L (IQR, 41\u20132238), total bilirubin 2.7 mg\/dl (IQR, 1.0\u20135.1), and INR two (IQR, 1.5\u20132.6). The median first hemofilter life censored for causes other than clotting exceeded 70 hours. The cumulative incidence of hypernatremia (Na &gt;148 mM), metabolic alkalosis (HCO3- &gt;30 mM), and hypophosphatemia (\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;2 mg\/dl) were one out of 26 (4%), zero out of 30 (0%), and one out of 30 (3%), respectively, and were not clinically significant. Mild hypocalcemia occurred in the first 4 hours in two out of 31 patients, and corrected by hour 6 with no additional Ca supplementation beyond the per-protocol administered Ca infusion. The maximum systemic total Ca (tCa; mM)\/ionized Ca (iCa; mM) ratio never exceeded 2.5.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The Shock protocol can be used without contraindications and is effective in maintaining circuit patency with a high, fixed ACDA infusion rate to blood flow ratio. Keeping single-pass citrate extraction on the dialyzer &gt;0.75 minimizes the risk of citrate toxicity even in patients with absent citrate metabolism. Precalculated, personalized dosing of the initial Ca-infusion rate from a table on the basis of the patient\u2019s albumin level and the filter effluent flow rate maintains neutral CKRT circuit calcium mass balance and a normal systemic iCa level.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.34067\/kid.0005342020","type":"journal-article","created":{"date-parts":[[2020,12,23]],"date-time":"2020-12-23T13:09:37Z","timestamp":1608728977000},"page":"192-204","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":32,"title":["Regional Citrate Anticoagulation Protocol for Patients with Presumed Absent Citrate Metabolism"],"prefix":"10.34067","volume":"2","author":[{"given":"Balazs","family":"Szamosfalvi","sequence":"first","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vidhit","family":"Puri","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryann","family":"Sohaney","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin","family":"Wagner","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Riddle","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sharon","family":"Dickinson","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lena","family":"Napolitano","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Heung","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Humes","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8955-1292","authenticated-orcid":false,"given":"Lenar","family":"Yessayan","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2021,2,25]]},"reference":[{"key":"B1-20250825","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.1007\/s00134-007-0754-4","article-title":"Continuous renal replacement therapy: A worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators","volume":"33","author":"Uchino","year":"2007","journal-title":"Intensive Care Med"},{"key":"B2-20250825","doi-asserted-by":"crossref","first-page":"2361","DOI":"10.1111\/j.1523-1755.2005.00342.x","article-title":"Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients","volume":"67","author":"Kutsogiannis","year":"2005","journal-title":"Kidney Int"},{"key":"B3-20250825","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1007\/s00134-003-2047-x","article-title":"Citrate vs. heparin for anticoagulation in continuous venovenous hemofiltration: A prospective randomized study","volume":"30","author":"Monchi","year":"2004","journal-title":"Intensive Care Med"},{"key":"B4-20250825","first-page":"602","article-title":"Regional citrate versus heparin anticoagulation during venovenous hemofiltration in patients at low risk for bleeding: Similar hemofilter survival but significantly less bleeding","volume":"20","author":"Betjes","year":"2007","journal-title":"J Nephrol"},{"key":"B5-20250825","doi-asserted-by":"crossref","first-page":"2450","DOI":"10.1097\/01.CCM.0000084871.76568.E6","article-title":"Citrate pharmacokinetics and metabolism in cirrhotic and noncirrhotic critically ill patients","volume":"31","author":"Kramer","year":"2003","journal-title":"Crit Care Med"},{"key":"B6-20250825","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1159\/000245648","article-title":"Automated regional citrate anticoagulation: Technological barriers and possible solutions","volume":"29","author":"Szamosfalvi","year":"2010","journal-title":"Blood Purif"},{"key":"B7-20250825","doi-asserted-by":"crossref","first-page":"1056","DOI":"10.1038\/sj.ki.5000196","article-title":"Downloadable computer models for renal replacement therapy","volume":"69","author":"Walther","year":"2006","journal-title":"Kidney Int"},{"key":"B8-20250825","doi-asserted-by":"crossref","first-page":"e65992","DOI":"10.1371\/journal.pone.0065992","article-title":"Citrate pharmacokinetics in critically ill patients with acute kidney injury","volume":"8","author":"Zheng","year":"2013","journal-title":"PLoS One"},{"key":"B10-20250825","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s40560-015-0102-7","article-title":"Implementation of continuous renal replacement therapy with regional citrate anticoagulation on a surgical and trauma intensive care unit: Impact on clinical and economic aspects-an observational study","volume":"3","author":"Hafner","year":"2015","journal-title":"J Intensive Care"},{"key":"B11-20250825","doi-asserted-by":"crossref","first-page":"R111","DOI":"10.1186\/cc11403","article-title":"Regional citrate anticoagulation in cardiac surgery patients at high risk of bleeding: A continuous veno-venous hemofiltration protocol with a low concentration citrate solution","volume":"16","author":"Morabito","year":"2012","journal-title":"Crit Care"},{"key":"B12-20250825","doi-asserted-by":"crossref","first-page":"68","DOI":"10.3904\/kjim.2011.26.1.68","article-title":"Regional anticoagulation with citrate is superior to systemic anticoagulation with heparin in critically ill patients undergoing continuous venovenous hemodiafiltration","volume":"26","author":"Park","year":"2011","journal-title":"Korean J Intern Med"},{"key":"B13-20250825","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1053\/jcrc.2003.50006","article-title":"A novel regional citrate anticoagulation protocol for CRRT using only commercially available solutions","volume":"18","author":"Tobe","year":"2003","journal-title":"J Crit Care"},{"key":"B14-20250825","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1097\/CCM.0000000000001004","article-title":"A randomized controlled trial of regional citrate versus regional heparin anticoagulation for continuous renal replacement therapy in critically ill adults","volume":"43","author":"Gattas","year":"2015","journal-title":"Crit Care Med"},{"key":"B15-20250825","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1093\/ndt\/gfq575","article-title":"Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: A prospective randomized multicentre trial","volume":"26","author":"Hetzel","year":"2011","journal-title":"Nephrol Dial Transplant"},{"key":"B16-20250825","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1186\/s13054-014-0472-6","article-title":"Citrate anticoagulation versus systemic heparinisation in continuous venovenous hemofiltration in critically ill patients with acute kidney injury: A multi-center randomized clinical trial","volume":"18","author":"Schilder","year":"2014","journal-title":"Crit Care"},{"key":"B17-20250825","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1172\/JCI104306","article-title":"Ion association. VI. Interactions between calcium, magnesium, inorganic phosphate, citrate and protein in normal human plasma","volume":"40","author":"Walser","year":"1961","journal-title":"J Clin Invest"}],"container-title":["Kidney360"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0005342020","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T20:02:54Z","timestamp":1786478574000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0005342020"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,2]]},"references-count":16,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2021]]}},"URL":"https:\/\/doi.org\/10.34067\/kid.0005342020","relation":{},"ISSN":["2641-7650"],"issn-type":[{"value":"2641-7650","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,2]]},"assertion":[{"value":"2020-09-08","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2020-12-18","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}