Heparin-free regional anticoagulation of haemodialysis filters with calcium-free dialysate: is citrate mandatory?

Abstract

Background There is an unmet need to develop safe and successful heparin-free regional anticoagulation modalities in haemodialysed patients at risk of bleeding. Whether the addition of citrate as a prefilter injection or in the dialysate itself is required to reach anticoagulation objectives when calcium-free dialysate is used as regional anticoagulation remains unclear. Methods In this monocentric retrospective study, we report our experience of 908 dialysis sessions performed with a calcium-free citrate-containing dialysate and calcium reinjection according to the ionic dialysance, without additional heparin. Results Premature termination for filter clotting occurred in 20 sessions (2.2%) and duration of session was >4.5 h in 135 (15%; maximum duration 6 h). In addition, we could investigate the citrate, calcium and acid–basis status during haemodialysis sessions performed with (citrate group, n = 20 sessions) or without (citrate-free group, n = 19 sessions) citrate in the dialysate. In 20 sessions performed in patients with underlying liver disorders and using calcium-free citrate-containing dialysate, patients’ ionized calcium (iCa) and serum citrate levels were stable and remained within the normal range, respectively. Post-filter iCa was below 0.4 mmol/L in 19/20 sessions and citrate was 0.304 mmol/L (range: 0.011; 0.548). In 19 sessions that used calcium and citrate-free dialysate, post-filter iCa was 0.41 mmol/L (0.34; 0.5) and all sessions extended to 4 h or beyond. Conclusions Regional anticoagulation of haemodialysis with a calcium-free dialysate and calcium reinjection according to the ionic dialysance is safe. Adding citrate to the dialysate is not mandatory to prevent dialysis circuit clotting in most patients.

Can regional anticoagulation with calcium‐free dialysate be extended to maintenance hemodialysis?

“…They confirmed the efficacy and safety of this feedback over a total of more than 1250 sessions with numerous types of dialyzers (Figure 3). In the study by Medrano et al reporting the largest number of sessions, no patient out of 316 developed symptomatic dyscalcemia during the 908 dialysis sessions lasting between 3.5 and 6 h, 4 and no symptomatic dyscalcemia was reported in any of the other studies. The use of calciumfree dialysate can thus be simplified, as it is no longer necessary to monitor blood calcium levels during dialysis.…”

“…Since these two studies, several others have confirmed the efficacy of this procedure. They showed a comparable percentage of sessions having to be interrupted prematurely due to filter clotting: 3 out of 101 (3%) 7 by Faguer et al., no sessions out of 44 (0%) by Vigneron et al., 8 20 out of 908 (2.2%) by Medrano et al., 4 3 out of 96 (3.2%) by Faguer et al 9 . In all, only 27 sessions out of 1228 (2.2%) failed.…”

“…Since these two studies, several others have confirmed the efficacy of this procedure. They showed a comparable percentage of sessions having to be interrupted prematurely due to filter clotting: 3 out of 101 (3%) 7 by Faguer et al, no sessions out of 44 (0%) by Vigneron et al, 8 20 out of 908 (2.2%) by Medrano et al, 4 3 out of 96 (3.2%) by F I G U R E 2 Automated feedback of ionic dialysance on infusion rate of the replacement solution during DuoCart Biofiltration (DCB) sessions. DCB is a hemodialysis procedure using a dialysate produced from two powder cartridges of sodium bicarbonate (BiCart) and sodium chloride (SelectCart).…”

“…Firstly, Medrano et al. observed no premature interruptions during the 19 sessions (lasting between 240 and 270 min) using calcium‐ and citrate‐free dialysate 4 . This suggests that citrate is not mandatory for effective regional anticoagulation with calcium‐free dialysate.…”

Alleviation of Oxidative Stress during Hemodialysis Sessions by Hemodialysis Membrane Innovation: A Multidisciplinary Perspective

“…Notably, it remains essential to consider the place of vitamin E-coated membranes in the broader context of currently available heparin-free dialysis techniques, such as regional citrate anticoagulation (RCA) and predilution hemodiafiltration. Owing to its safety and efficacy, RCA has been widely adopted in clinical practice for both critically ill and hemodialysis patients at high risk of bleeding and filter clotting [28][29][30]. However, the utilization of RCA is not devoid of challenges.…”