An Observational Cohort Study of the 2-Month Use of Regional Citrate Anticoagulation in Maintenance Hemodialysis Patients with Cerebral Hemorrhage

Abstract

Background Regional citrate anticoagulation (RCA) is a recommended anticoagulation alternative for patients at high risk of bleeding while undergoing intermittent hemodialysis. Previous reports implied the risk of citrate application on bone metabolism. It is unclear whether long-term use of RCA is safe for maintenance hemodialysis patients in terms of bone metabolism. Material/Methods Seven patients with cerebral hemorrhage were included in the study. Blood samples were collected at baseline and 4 and 8 weeks after treatment. Spent dialysate samples were collected during each mid-week dialysis session, using the partial dialysate collection method. All patients were treated with RCA for 4 to 8 weeks, according to their clinical condition. We assessed bone metabolism-associated parameters, bone turnover markers, and magnesium loss at each dialysis session. Results Serum magnesium levels were 1.24±0.13 mmol/L at baseline and significantly decreased to 1.16±0.14 mmol/L after 4 weeks of RCA treatment ( P =0.025). Most patients had negative magnesium balance during citrate hemodialysis. Serum total calcium levels did not change significantly after treatment. One bone marker, N-terminal propeptide of type I procollagen (PINP), significantly decreased from 146.07±130.12 mmol/L to 92.42±79.01 mmol/L after citrate treatment ( P =0.018). No significant changes were detected in other bone turnover markers. Conclusions Relatively long-term RCA treatment may decrease serum magnesium levels due to negative magnesium balance. Bone formation marker PINP seemed to decrease after treatment, while other bone turnover markers did not change significantly. Further investigation is needed to verify the effect of RCA on bone remodeling.

Use of regional citrate anticoagulation with medium cut-off membrane: pilot report

“…[17] The results of patients on high-flux HD show that RCA may decrease serum magnesium levels, possibly due to a negative magnesium balance. [10,17] Our findings show that a decrease in serum magnesium levels might occur in HDx as well: we observed three cases of mild, post-dialysis asymptomatic hypomagnesemia, which did not require magnesium substitution. It is expected, as citrate is metabolized to bicarbonate, that magnesium (as well as calcium) would be released after HD.…”

“…[6] Given all its benefits, citrate has already become the standard anticoagulant in acute kidney injury requiring continuous renal replacement therapy, not only for adults [7], but also for pediatric patients [8]. Furthermore, RCA is being increasingly used in various intermittent HD modalities, such as chronic high-flux [6,9,10] and lowflux HD [11], hemodiafiltration with a high cut-off (Ther-alite®) membrane [12], and single-needle HD [13].…”