Tailoring dialysis prescription in a critically ill patient with AKI: the role of Regional Citrate Anticoagulation as a tool for acid-base optimization.

Tailoring dialysis prescriptions in critically ill patients with severe acute kidney injury (AKI) represents a significant challenge, requiring a balance between adequate solute clearance and the minimization of treatment-related complications. Recent evidence highlights the potential advantages of a low dialysis dose in limiting electrolyte disturbances, preserving essential nutrients, and reducing the need for pharmacologic interventions, while maintaining effective metabolic control. Regional citrate anticoagulation (RCA), widely considered as the first anticoagulation strategy for Continuous Kidney Replacement Therapy (CKRT), also contributes to dialysis buffer balance through the indirect generation of bicarbonate from citrate metabolism. In this regard, modulation of citrate metabolic load may allow the optimization of acid-base balance without increasing dialysis intensity. Therefore, RCA may represent a versatile tool to individualize CKRT prescriptions, enabling both effective metabolic management and lower dialysis doses, thereby enhancing patient safety and therapeutic efficiency in the intensive care setting.