**Background:** Continuous renal replacement therapy (CRRT) is increasingly performed in Chinese emergency departments due to limited critical care resources. Anticoagulation is essential to prevent clotting in the extracorporeal circuit. Systemic heparin anticoagulation (SHA), previously the standard, has significant limitations including contraindications in bleeding patients, heparin-induced thrombocytopenia (HIT), and high complication rates. Regional citrate anticoagulation (RCA) has emerged as a safer and more effective alternative, recommended as the preferred method by KDIGO guidelines. However, lack of unified management protocols has led to treatment failures and complications, prompting the Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) to develop this consensus guideline.
**Methods:** The guideline was developed by a panel of 45 experts (including 3 international consultants) from emergency medicine, critical care, and guideline methodology. Literature was searched in PubMed, Medline, Cochrane, CNKI, Wanfang, and VIP databases from January 1960 to March 2023. The expert group conducted 22 rounds of discussion and revision via online meetings. A Delphi survey was conducted among 42 experts using a 7-point Likert scale. Consensus was defined as >75% of experts scoring ≥6. Sixteen recommendations achieved consensus. Evidence quality and recommendation strength were graded using the GRADE framework (Advanced/Intermediate/Low evidence quality; Strong/Medium/Weak recommendation strength).
**Key Results:** The guideline presents 16 specific recommendations:
1. RCA is recommended as the preferred anticoagulation method for CRRT (agreement 92.9%, evidence quality I, recommendation strength A). A meta-analysis of 30 studies showed filter coagulation was significantly delayed with RCA vs SHA (mean difference 15.69 h, 95%CI 9.30–22.08). A prospective multicenter RCT showed RCA reduced system downtime in the first 72 h (1 h vs 3 h), fewer treatment interruptions due to coagulation (24% vs 51%), and fewer filter replacements (9% vs 30%). Two meta-analyses showed lower bleeding risk with RCA (RR=0.31, 95%CI 0.19–0.51; RR=0.34, 95%CI 0.17–0.65).
2. Initial citrate dose should be based on blood flow rate, targeting filter ionized calcium (iCa) of 0.2–0.4 mmol/L (agreement 97.6%, evidence I, strength A).
3-4. For calcium-free replacement fluid, initial 4% TSC flow rate = blood flow rate (ml/min) × 1.5; for calcium-containing fluid, × 1.7. Target filter iCa 0.2–0.4 mmol/L (agreement 100%, evidence II, strength C).
5-7. Calcium supplementation is mandatory to maintain in vivo iCa at 0.9–1.1 mmol/L (agreement 90.4–100%). Initial 5% calcium chloride = effluent flow rate/200; 10% calcium gluconate = effluent flow rate/125.
8. Metabolic alkalosis is the most common complication (incidence 29–50%). Management includes reducing extra bicarbonate, increasing replacement fluid/dialysate flow, or reducing citrate infusion (agreement 92.9%, evidence II, strength C).
9-11. Citrate accumulation warning signs: total-Ca/iCa ratio >2.25 and increasing, worsening ionized hypocalcemia, increasing calcium requirements. Management includes optimizing hemodynamics, reducing citrate infusion, or changing anticoagulant method (agreement 95.2%). In a retrospective study of 1070 patients, citrate accumulation occurred in 32 (2.99%), with 0% survival among those patients.
12. Close monitoring of serum electrolytes, especially iCa and magnesium, is required (agreement 97.6%, evidence III, strength B).
13-14. Liver dysfunction and lactic acidosis are not contraindications to RCA but require close monitoring (agreement 92.9%, evidence II, strength C).
15. RCA is not recommended in SCUF mode but can be used in CVVH, CVVHD, and CVVHDF (agreement 95.2%, evidence III, strength C).
16. RCA provides 350–900 extra kcal/day from citrate metabolism, which should be included in nutritional management (agreement 95.2%, evidence III, strength C).
**Clinical Implications:** This guideline provides the first comprehensive, consensus-based recommendations for RCA management during CRRT specifically tailored for Chinese emergency departments. It establishes standardized protocols for citrate dosing, calcium supplementation, and monitoring that can reduce complications and improve treatment efficacy. Importantly, it challenges traditional contraindications by stating that liver dysfunction and lactic acidosis are not absolute barriers to RCA use, though such patients require heightened surveillance. The emphasis on individualized target values for filter iCa (rather than rigid ranges) reflects practical clinical experience. The guideline also highlights the need to account for RCA's caloric contribution in patient nutrition management—a frequently overlooked aspect. These recommendations should facilitate wider adoption of RCA in Chinese emergency departments and potentially reduce bleeding complications compared to heparin-based anticoagulation.