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CRRT Regional Anticoagulation Using Citrate in the Liver Failure and Liver Transplant Population

Wonnacott, Rob MSN, RN; Josephs, Brandi BSN, RN; Jamieson, Jill MSN, RN

doi: 10.1097/CNQ.0000000000000118
Original Articles

Regional citrate for continuous renal replacement therapy (CRRT) use in patients with liver failure or post–liver transplant has been considered a contraindication because of the risk of citrate toxicity development. Regional citrate has the benefit of decreased bleeding risks over systemic anticoagulation; therefore, it is of great benefit to the coagulopathic and surgical populations. This article analyzes current empiric data and compares with a case study specifically related to liver failure, liver transplant, and CRRT use. We found that the use of a total serum to ionized calcium ratio was much more reliable in measuring liver function than liver enzyme figures. This when paired with a citrate-reduction guideline based on serum to ionized calcium ratios provided effective, early management of citrate toxicity. Using new measurements to calculate liver metabolism of citrate and using a new citrate-reducing guideline allow the bedside practitioner to use regional citrate anticoagulation in patients with liver failure and liver transplant who require CRRT.

Surgical Intensive Care Unit (Mr Wonnacott), Cardiovascular Intensive Care Unit, Samuel and Jean Frankel Cardiovascular Center (Ms Josephs), and Acute/Nocturnal Hemodialysis Interventional Nephrology Unit (Ms Jamieson), University of Michigan Health Systems, Ann Arbor.

Correspondence: Rob Wonnacott, MSN, RN, Surgical Intensive Care Unit, University of Michigan Health Systems, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (

The authors acknowledge the vast amount of work done by the University of Michigan CRRT core instructor group in helping make this article possible, with special mention to Jan Schuette, RN, and Lauren Smith, RN, for their assistance in gathering needed data. The authors also thank Dr M. Heung, Director of Inpatient Dialysis, and Dr L. Napolitano, Director of Acute Care Surgery, for their support and encouragement in this endeavor; Ernie Saxton, BSN, RN, Cari Coscia, RN, and Amanda York, BSN, RN, for being there to assist in any way possible; and Sharon Dickinson, MSN, RN, CNS, NP, CCRN, who has supported and mentored the entire process and really made this article possible.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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