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Citrate toxicity while on CRRT
A potential complication of CRRT is Citrate toxicity. When citrate enters the patient’s circulation, each mole of citrate is potentially metabolized in the Krebs cycle to bicarbonate mostly in the liver mitochondria. Metabolic acidosis can occur when citrate accumulates in patients who cannot metabolize citrate (weak acid), such as those with liver failure. The criteria that we use to detect citrate toxicity include worsening metabolic acidosis, ionized hypocalcemia from unmetabolized calcium-citrate complexes, rising total calcium levels which lead to a disproportional rise in total systemic calcium to ionized calcium ratio of greater than 2.5. Therapy involves reducing or discontinue citrate infusion, increasing convective or diffusive clearance of citrate and increasing calcium infusion to correct ionized hypocalcemia. Unsure if uncommon or under reported, share your experience in this thread. 

Summary provided by Jorge Castaneda, MD
Previous Community Minded Summaries are available at: