CKRT: Troubleshooting

Citrate Toxicity

• Indicates excess citrate in the body. Citrate is binding to the calcium and not being metabolized fast enough to liberate the calcium. However, because of separate calcium drip, pt sees enough free calcium to be asymptomatic.

• Diagnosis:

  • High total calcium (bound) with a normal ionized calcium.

  • Typically ratio greater than 10:1. (Total Ca usually > 14-15, iCa usually 1.1-1.3)

  • Also with alkalosis. UNLESS pt has liver dysfunction and cannot metabolize. Could then be high AGMA (anion-gap metabolic acidosis). Citrate is an anion until converted to bicarb by the liver

• Treatment:

  • Adjust iCa goals (can increase circuit iCa or decrease pt iCa targets)

    • Could put you at risk for clotting circuit

  • Can also increase Qd (dialysate flow) to help with clearance of citrate

  • Could potentially change to 4K/22mEq HCO3 bicarb bags. Special order from adult pharmacy. Ideal to help with alkalosis, not necessarily for citrate.

  • If pt is getting low dose systemic heparin, can request the heparin go into circuit first. Allows some anticoagulation and then can increase circuit iCa goals.