• Hasan S Kihtir, Muhterem Duyu, Mehmet E Mementoglu, Ilknur Tolunay, Tanil Kendirli, Faruk Ekinci, Edin Botan, Ebru A Ongun, Ayse Asik, Emrah Gun, Hacer Ucmak, Esra Sevketoglu, and Dincer Yildizdas.
• Department of Pediatric Critical Care, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey.
• Pediatr Crit Care Me. 2024 Dec 19.

ObjectivesTo examine citrate anticoagulation in continuous renal replacement therapy (CRRT) in the PICU.DesignPost hoc analysis of a curated, multicenter dataset collected from January 1, 2022, to June 1, 2023.SettingSeven PICUs in Turkey.PatientsPICU admissions in need of CRRT, 28 days to 18 years old.InterventionsNone.Measurements And Main ResultsIn 128 filters used in 73 patients, the effective filter life (EFL) restricted to 72 hours was a median (interquartile range [IQR]) of 40.5 hours (IQR, 21-58 hr); total EFL was a median of 59 hours (IQR, 28-89 hr). Analysis of the receiver operating characteristic curve for initial citrate infusion dose (CID) and whether EFL reached 72 hours identified a cutoff level for initial CID of greater than 2.64 mmol citrate per liter of patient blood flow (mmol/L-bf). As expected, the two filter groups categorized by initial CID (≥ 2.7 vs. < 2.7 mmol/L-bf) showed filters in children receiving higher initial dosing had longer total EFL (72 hr [IQR, 48-104 hr] vs. 38.5 hr [IQR, 18-84 hr]; p = 0.03). We failed to identify an association between CRRT for over 24 or 48 hours and greater odds (odds ratio [OR], 95% CI) of citrate accumulation (OR, 2.23; 95% CI, 0.82-6.13; p = 0.118 or OR, 1.78; 95% CI, 0.84-3.8; p = 0.134, respectively). However, we cannot exclude up to 6.1- or 3.8-fold odds of citrate accumulation; of note, CRRT over 72 hours was associated with greater odds of citrate accumulation (OR, 2.17; 95% CI, 1.01-4.68; p = 0.04). Citrate lock syndrome occurred in eight of 128 (6.3%; 95% CI, 3-11.4%) filters, and resolved without termination of CRRT. On multivariable analysis, a higher patient initial lactate concentration was associated with an 18% (95% CI, 7-30%) greater hazard of developing citrate accumulation.ConclusionsCitrate anticoagulation for CRRT is an option for children. Choosing an initial CID greater than or equal to 2.7 mmol/L-bf provides longer EFL but with the associated potential of citrate accumulation. Further studies are needed on initial CID and duration of EFL.Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

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