Regional Citrate Anticoagulation During Continuous Renal Replacement Therapy; Should It Be the First Choice Over Heparin in Children?

Regional citrate anticoagulation (RCA) has gained increasing attention as a superior anticoagulation strategy in pediatric continuous renal replacement therapy (CRRT). Compared to systemic heparin anticoagulation (SHA), RCA offers significant advantages, including prolonged circuit lifespan, reduced clotting rates, and a lower incidence of bleeding complications. While heparin remains widely used due to its availability and ease of administration, its systemic effects, particularly the risk of bleeding and heparin-induced thrombocytopenia, pose considerable challenges in critically ill children. Studies have consistently demonstrated that RCA reduces transfusion requirements and enhances circuit survival without increasing bleeding risk. Despite potential metabolic concerns such as citrate accumulation, metabolic alkalosis, and electrolyte imbalances, these risks can be effectively managed with careful monitoring and protocol adjustments. As pediatric CRRT protocols continue to evolve, RCA is emerging as the preferred first-line anticoagulation method, particularly in patients with high bleeding risk. The growing body of evidence supports its wider clinical application, promising better treatment outcomes and improved survival rates in critically ill pediatric patients requiring CRRT.