Regional
citrate anticoagulation (RCA) for
continuous renal replacement therapy (CRRT) has become increasingly attractive in recent years due to its favourable low
bleeding risk profile. Its use in
liver failure, however, has been limited due to the risk of
citrate accumulation and toxicity. In the previous issue of
Critical Care, Schultheiss and colleagues look at CRRT using RCA in
liver failure patients. They demonstrate that
citrate accumulation can be predicted using the total
calcium (Ca(tot)) to ionised
calcium (Ca(ion)) ratio (Catot/Ca(ion)), and determine that despite the occurrence of significant
citrate accumulation, the effects of
citrate accumulation are not as severe as might have been expected. This study raises interesting prospects with regard to RCA use in
liver failure, and we postulate that
citrate may have a role as a prognostic marker of metabolic capacity much as in the way of
lactate and
methacetin. However, further studies are warranted, in particular examining its application in subgroups of
liver failure (chronic, acute, hyperacute and subacute), before its use becomes commonplace.