Bicarbonate-Based Solution for Prefilter in CRRT to Reduce Clotting

Rationale for Bicarbonate-Based Solutions

The KDIGO guidelines recommend bicarbonate over lactate as a buffer in dialysate and replacement fluid for CRRT in patients with acute kidney injury (AKI) 1
Bicarbonate has replaced lactate and acetate as the dialysate buffer of choice for intermittent renal replacement therapy (RRT) and is preferred for CRRT, according to the American Journal of Kidney Diseases 2, 3
Bicarbonate is strongly recommended (1B recommendation) for patients with AKI and circulatory shock, as stated by the American College of Cardiology 1
Bicarbonate is suggested (2B recommendation) over lactate for patients with AKI and liver failure and/or lactic acidemia, according to the American College of Cardiology 1

Prefilter fluid administration dilutes the blood before it enters the hemofilter, enhancing the achievable ultrafiltration rate and reducing the risk of filter clotting, as recommended by the American Society of Nephrology 1

Use anticoagulation for patients receiving RRT who are not at increased risk of bleeding, as suggested by the American Journal of Kidney Diseases 2, 3
For patients with heparin-induced thrombocytopenia, all heparin must be stopped, and direct thrombin inhibitors or Factor Xa inhibitors should be used instead, according to the American College of Chest Physicians 1
In thrombocytopenic patients without contraindications to citrate, regional citrate anticoagulation is recommended over heparin, as stated by the American Society of Nephrology 1

The recommended CRRT effluent volume is 20-25 mL/kg/h, as suggested by the American Journal of Kidney Diseases and the American Society of Nephrology 2, 4
Monitor filter function regularly as available evidence suggests that delivery of RRT often falls short of the prescribed dose, according to the American Journal of Kidney Diseases 3
Warming the dialysate helps maintain hemodynamic stability during CRRT, as recommended by the American College of Cardiology 4

Monitor for electrolyte abnormalities that commonly develop during CRRT, including hypophosphatemia, hypokalemia, and hypomagnesemia, as suggested by the American Society of Nephrology 4
Ensure proper fluid balance monitoring to avoid significant errors in fluid balance, according to the American College of Cardiology 4