Background: Large-scale adoption of regional citrate anticoagulation (RCA) is prevented by risks of the technique as practiced traditionally. Safe RCA protocols with automated delivery on customized dialysis systems are needed. Methods: We applied kinetic analysis of solute fluxes during RCA to design a protocol for sustained low-efficiency dialysis (SLED) for critically ill patients. We used a high-flux hemodialyzer, a zero-calcium (Ca) dialysate, a dialysis machine with online clearance and access recirculation monitoring, and a separate optical hematocrit (Hct) sensor. Flow rates were QB = 200 ml/min for blood; QD = 400 ml/min for dialysate, with Na = 140 mmol/l and HCO3 = 32 mmol/l; Qcitrate = 400 ml/h of acid citrate dextrose A; ultrafiltration as indicated. The QCa was infused into the return blood line, adjusted hourly based on online Hct and a 1 mmol/l in the blood reservoir and
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