Regional Citrate Anticoagulation for Single-Needle Hemodialysis: A Prospective Clinical Study

Gubenšek, Jakob; Buturović‐Ponikvar, Jadranka; Ponikvar, Rafael

doi:10.1159/000111808

Cited by 10 publications

(15 citation statements)

References 13 publications

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“…In regional citrate anticoagulation (RCA) , citrate chelates calcium and blocks the coagulation cascade by lowering the ionized calcium level in ECC, which can be further reduced by using a calcium‐free dialysate . RCA is cumbersome and time consuming, given that monitoring of ionized calcium is mandatory to avoid hypo‐ and hypercalcemia.…”

Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under-and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel lowmolecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.Maintaining full patency in the extracorporeal circuit (ECC) during hemodialysis (HD) sessions is a prerequisite for optimal HD quality (1-4). A complex disturbance of the coagulation system is commonly encountered in patients at the terminal stage of chronic kidney disease (CKD), leading to considerable morbidity and mortality (5). Although HD reduces the bleeding risk by the removal of uremic toxins, interaction between blood and artificial surfaces contributes to activate coagulation pathways. This nonphysiological environment leads to clotting on these foreign surfaces which reduces HD efficiency, shortens circuit lifetime, and increases patient blood loss, nursing workload, disposable consumption, and thus the cost of treatment (3,4).Appropriate anticoagulation requires a subtle balance between under-and over-heparinization to prevent ECC clotting and bleeding, respectively. HD patients are prone to prolonged bleeding episodes from dialysis fistula, as well as gastrointestinal and intracranial hemorrhage (5). Conversely, they may develop a prothrombotic status or comorbid conditions requiring oral anticoagulants or antiplatelet agents (1,5). Of interest, the dialysis population represents the only group of patients to receive heparin three times per week, with a potential longterm cumulative effect associated with an increased risk of osteoporosis, aldosterone suppression and hyperkalemia, and a deterioration of lipid profile...

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Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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“…Several studies in adults and a number in the pediatric age group have validated the safety and efficacy of this protocol [2][3][4][5][6][7][8][9]. Citrate was used as an anticoagulant in up to 56% of CRRT sessions performed at the North American centers participating in the Prospective Pediatric Continuous Renal Replacement Therapy Registry [10].…”

Section: Introductionmentioning

confidence: 99%

“…Protocols for monitoring an adequate extracorporeal anticoagulation in RCA have been reported, with activated coagulation time (ACT) and post-filter ionized calcium (iCa) level being the most commonly used parameters [2][3][4][5][6][7][8][9]. Standard values for ACT in children are non-existent, and recommendations for ACT in pediatric hemodialysis are mostly empiric and heavily dependent on the method and equipment used [e.g.…”

Section: Introductionmentioning

confidence: 99%

“…>120 s for the ACTester (Quest Medical, Allen, TX) and >170 s for the Hemochron (International Technidyne, Edison, NJ)] [11]. If the postfilter iCa is used for coagulation monitoring, the target value varies between ≤0.50 and ≤0.25 mmol/l depending on the particular study [1][2][3][4][5][6][7][8][9]. Although studies in vitro have demonstrated the association of iCa levels and coagulation time [12,13], to the best of our knowledge no precise target value based on the anticoagulation measurement of postfilter iCa has been established.…”

Section: Introductionmentioning

confidence: 99%

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Management of regional citrate anticoagulation in pediatric high-flux dialysis: activated coagulation time versus post-filter ionized calcium

et al. 2010

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Recent years has seen an increasing use of regional citrate anticoagulation in pediatric dialysis. Several approaches have been described for monitoring anticoagulation in the extracorporeal circuit, such as serum citrate levels, post-filter ionized calcium (iCa), and activated coagulation time (ACT). However, no standard recommendations have yet been established for applying any of these parameters, especially for iCa. The objective of this retrospective analysis was to establish adequate coagulation management using post-filter iCa values. Normal values for ACTester-based ACT were established using a group of 64 children who were divided into two subgroups, with one subgroup comprising children without chronic kidney disease or coagulation disorder (age 1.2-17.5 years, median 9.7 years) and one consisting of 32 uremic patients (age 0.6-17.5 years, median 13.7 years). In a second group of 13 patients (aged 7-17 years), all of whom were undergoing high-flux dialysis (HD) with regional citrate anticoagulation (RCA), we assessed 73 post-filter blood samples for ionized calcium and ACT. A receiver operating characteristic graph was used to identify the iCa threshold needed to achieve adequate anticoagulation. Normal values for ACT were 90 s [2 standard deviations (SD) 72-109] in healthy children and 94 s (2 SD 75-113) in the uremic children. There was no statistically significant difference between the groups. In the children undergoing HD with RCA, the post-filter iCa level correlated with ACT (r = -0.94, p < 0.001). A post-filter iCa level of < or = 0.30 mmol/l reliably predicted an ACT >120 s. Our citrate protocol [citrate 3% rate (ml/h) approximately blood flow rate (ml/min) x 2] meets the established criteria with a high sensitivity. Based on these results, we conclude that the post-filter iCa level can be reliably used for the management of extracorporeal anticoagulation with citrate in pediatric HD. We recommend the application of our citrate prescription protocol in the setting of pediatric intermittent hemodialysis.

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“…SN apheresis is already being used for hemodialysis [10,11] and platelet apheresis [12], and its effectiveness and safety have already been reported. Hemodialysis patients were treated using the SN technique for the following reasons: to decrease the risk of early arteriovenous fistula failure, to facilitate cannulation for nurses, and to reduce the pain burden for the patient [13][14][15].…”

Section: Discussionmentioning

confidence: 99%