Regional citrate anticoagulation (RCA) is the preferred anticoagulation strategy for continuous renal replacement therapy (CRRT). However, its implementation remains challenging in developing countries because of protocol complexity, intensive laboratory monitoring, and concerns regarding treatment costs. We report our initial experience implementing RCA in a resource-limited intensive care unit (ICU) in Indonesia.

A single-center retrospective observational study was conducted in adult critically ill patients receiving CRRT over a two-year period at Mayapada Hospital Bandung, Indonesia. Clinical feasibility and direct institutional costs of RCA were descriptively compared with conventional systemic heparin anticoagulation. Cost analysis included CRRT consumables, anticoagulants, and laboratory monitoring. RCA monitoring consisted of ionized and systemic calcium measurements three times daily, whereas patients receiving systemic heparin underwent prothrombin time (PT) and activated partial thromboplastin time (aPTT) monitoring every 12 hours. All costs are presented in Indonesian Rupiah (IDR), with approximate United States Dollar (USD) and New Taiwan Dollar (NT$) equivalents.

Six patients underwent CRRT, including four treated with RCA and two with systemic heparin. RCA was successfully introduced into routine clinical practice using a standardized institutional protocol without major barriers. The institutional cost of RCA-based CRRT was approximately IDR 85 million (USD 4,760; NT$151,000) for a 3-day treatment and IDR 100 million (USD 5,600; NT$178,000) for 4 days, compared with IDR 80 million (USD 4,480; NT$142,000) for 3-day systemic heparin therapy. Routine laboratory monitoring for RCA cost approximately IDR 3.02 million/day (USD 169; NT$5,380/day) compared with IDR 1.85 million/day (USD 104; NT$3,290/day) for systemic heparin. No statistical analysis was performed because of the small sample size.

RCA can be successfully implemented in a resource-limited ICU in Indonesia using a standardized protocol. Although RCA requires more intensive laboratory monitoring and slightly higher direct costs than systemic heparin, implementation was feasible in our setting. Larger prospective studies are needed to evaluate filter lifespan, circuit survival, bleeding complications, and cost-effectiveness in developing countries.