Nephrology Division, NYU Grossman School of Medicine and Nephrology Section, NY Harbor VA Healthcare System, New York, New York, USA.
Curr Opin Nephrol Hypertens. 2024 Mar 1;33(2):181-185. doi: 10.1097/MNH.0000000000000953. Epub 2023 Nov 14.
Continuous renal replacement therapy (CRRT) is a vital medical intervention used in critically ill patients with acute kidney injury (AKI). One of the key components of adequate clearance with CRRT is the use of anticoagulants to prevent clotting of the extracorporeal circuit. Regional citrate anticoagulation is the most often recommended modality. The term 'citrate toxicity' is used to describe potential adverse effects of accumulation of citrate and subsequent hypocalcemia. However, citrate is itself not inherently toxic. The term and diagnosis of citrate toxicity are questioned in this review.
Citrate is being increasingly used for regional anticoagulation of the CRRT circuit. Citrate accumulation is infrequent and can cause hypocalcemia and metabolic alkalosis, which are potential adverse effects. Citrate itself, however, is not a toxic molecule. The term 'citrate toxicity' has been used to denote hypocalcemia and metabolic acidosis. However, citrate administration is well known to cause systemic and urinary alkalinization and under certain circumstances, metabolic alkalosis, but is not associated itself with any 'toxic' effects.We review the existing literature and debunk the perceived toxicity of citrate. We delve into the metabolism and clearance of citrate and question current data suggesting metabolic acidosis occurs as the result of citrate accumulation.
In conclusion, this article calls into question prevailing concerns about 'citrate toxicity'. We emphasize the need for a more nuanced understanding of its safety profile. We recommend discarding the term 'citrate toxicity' in favor of another frequently used, but more meaningful term: 'citrate accumulation'.
连续肾脏替代疗法（CRRT）是治疗急性肾损伤（AKI）危重症患者的重要医疗手段。CRRT 充分清除的关键之一是使用抗凝剂预防体外回路凝血。局部枸橼酸抗凝是最常推荐的方法。“枸橼酸盐毒性”一词用于描述枸橼酸盐蓄积和随后低钙血症的潜在不良反应。然而，枸橼酸盐本身并不具有毒性。本文对枸橼酸盐毒性的术语和诊断提出了质疑。
枸橼酸盐越来越多地用于 CRRT 回路的局部抗凝。枸橼酸盐蓄积不常见，但可引起低钙血症和代谢性碱中毒，这是潜在的不良反应。然而，枸橼酸盐本身并不是有毒分子。“枸橼酸盐毒性”一词用来表示低钙血症和代谢性酸中毒。然而，枸橼酸盐的使用众所周知会导致全身和尿碱化，在某些情况下会导致代谢性碱中毒，但本身与任何“毒性”作用无关。我们回顾了现有的文献，驳斥了枸橼酸盐被认为具有毒性的观点。我们深入研究了枸橼酸盐的代谢和清除，并对目前认为代谢性酸中毒是由于枸橼酸盐蓄积引起的数据提出了质疑。
综上所述，本文对普遍存在的关于“枸橼酸盐毒性”的担忧提出了质疑。我们强调需要更细致地了解其安全性特征。我们建议摒弃“枸橼酸盐毒性”这一术语，转而使用另一个常用但更有意义的术语：“枸橼酸盐蓄积”。
