Regional Citrate Anticoagulation for Intermittent Predilution Online Hemofiltration

Abstract

There is no consensus on the optimal renal replacement treatment in intensive care units. Among intermittent dialysis methods, hemofiltration (HF) is preferred by some because of better hemodynamic stability and cytokine removal. We report our experience with regional citrate anticoagulation for intermittent predilution online HF. Forty-one patients (age 69 +/- 10 years, 73% male) with acute renal failure and an increased bleeding risk in intensive care units were included in this retrospective analysis. Citrate anticoagulation was performed with 4% citrate (starting at 400 mL/h) and 1 mol/L calcium chloride (starting at 7 mL/h). Calcium-containing (1.25 mmol/L) infusate, prepared online, was used. Anticoagulation was assessed visually after HF in a subgroup of 36 procedures using a score of 5 (no clotting) to 1 (total occlusion). The duration of the 94 HF sessions performed was 4 h 50 min +/- 47 min, and the infusate volume reached was 77 +/- 9 L. During HF, ionized calcium increased (1.01 +/- 0.14 to 1.13 +/- 0.09 mmol/L, P < 0.001), and the increases in sodium (141 +/- 5 to 143 +/- 3 mmol/L, P < 0.001) and bicarbonate (23 +/- 6 to 25 +/- 4 mmol/L, P < 0.01) were significant, but small. There were two cases of metabolic alkalosis (pH > 7.5) not requiring any intervention. None of the circuits clotted. The mean anticoagulation assessment scores were 4.6 +/- 0.6 at the arterial bubble trap, 4.2 +/- 1.0 at the dialyzer, and 4.2 +/- 0.9 at the venous bubble trap. To conclude, regional citrate anticoagulation for predilution online hemofiltration with calcium-containing infusate provides a good anti-thrombotic effect and has rare metabolic side effects.

Is Regional Citrate Anticoagulation the Future of Hemodialysis?

“…According to our experience, predilution on‐line hemofiltration with the use of calcium‐containing infusate (1.25 mmol/L) and regional citrate anticoagulation was the only procedure that could be performed with calcium (in infusate) and without significant clotting in the dialysis circuit. Such a procedure required higher doses of citrate and lower doses of calcium supplementation as compared to standard hemodialysis with calcium‐free dialysate .…”

Citrate Anticoagulation During Post‐Dilution Hemodiafiltration With a High Cut‐Off (Theralite) Membrane

“…Although we do use calcium‐containing dialysate and infusate for citrate anticoagulation in case of intermittent hemofiltration (6), we decided to use calcium‐free dialysate and infusate in this setting with a separate calcium infusion, based on our experience with clotting problems in the venous bubble trap when calcium‐containing dialysate and infusate were used with HDF (7). Citrate metabolism was shown to be normal in patients with end‐stage renal failure (8), but is slower in patients with liver failure (9); and caution is also advised in patients with muscle hypoperfusion (i.e.…”

Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study

“…IHD sessions were performed using AK200 (Gambro®) generators and polysulfone high-flux membranes (Hemotech®). The RCA during IHD was performed according to the procedure previously described [ 14 , 17 , 18 ]. Sodium Citrate 4% (Fresenius®) was infused immediately downstream from the connection between the dialysis catheter and arterial line of the circuit (Additional file 1 : Figure S1).…”