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Citrate Accumulation Acidosis Dialysis — ESENeph MCQ

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HardAcid-BaseCitrate Accumulation Acidosis DialysisESENeph

A 60-year-old man with CKD G5D on haemodialysis develops severe lactic acidosis (pH 7.05, lactate 18 mmol/L) without obvious cause. He is not on Metformin. His dialysis lines were recently used with a citrate-containing catheter lock solution. What should be considered?

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Correct answer: A — Citrate accumulation from citrate anticoagulation or catheter lock solutions – in patients with impaired hepatic citrate metabolism (liver disease, shock), citrate can accumulate causing a characteristic pattern of metabolic acidosis with low ionised calcium

Citrate is metabolised to bicarbonate in the liver. In patients with impaired hepatic function (liver disease, hypoperfusion/shock), citrate accumulates. Accumulated citrate chelates ionised calcium (causing hypocalcaemia), and the unmeasured anion causes a high anion gap metabolic acidosis. This is a recognised complication of regional citrate anticoagulation during CRRT and can occur with citrate catheter lock solutions. The classic triad is: rising total calcium (bound to citrate), falling ionised calcium, and metabolic acidosis. Treatment involves stopping citrate and giving IV calcium.

Reference: Oudemans-van Straaten et al 2011 – Citrate Anticoagulation; KDIGO 2012 – AKI