Standard Citrate Versus Sequential Citrate/Anticoagulant‐free Anticoagulation During Hemodialysis: A Randomized Trial

Buturović, J; Gubenšek, Jakob; Černe, Darko; Ponikvar, Rafael

doi:10.1111/j.1525-1594.2007.00459.x

Cited by 21 publications

(25 citation statements)

References 6 publications

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“…Since a more coagulation-prone SN dialysis [6] was performed in this study and also INR was sub-therapeutic, the contribution to the antithrombotic effect in the circuit is considered minimal. Although the citrate dose (27 mmol/h) is lower than in double-needle dialysis (40-60 mmol/h) [2,7,8] citrate accumulation could have occurred due to the lower effective blood flow (SN setting), but the citrate concentrations measured after dialysis ( table 2 ) do not suggest this, as they were low and comparable to levels reported after double-needle dialysis [7,9,10] .To conclude, we have shown that regional citrate anticoagulation in SN hemodialysis provides a very good antithrombotic effect and has few metabolic complications. …”

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confidence: 47%

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

Gubenšek¹,

Buturović‐Ponikvar²,

Ponikvar³

2007

Blood Purif

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Aim: Regional citrate anticoagulation protocol for single-needle hemodialysis was tested prospectively for safety and efficacy. Methods: 15 chronic dialysis patients at risk of bleeding were included. 4 % trisodium citrate (200 ml/h), calcium-free dialysate and 1 mol/l calcium chloride (7 ml/h) were used. After dialysis the antithrombotic effect in the circuit was assessed visually (grade 5, no clotting, to 1, total occlusion) and serum citrate was measured. Results: Of 32 dialyses performed, 94% were uneventful and in 2 cases (6%) there was severe (ionized calcium ≤0.8 mmol/l) but asymptomatic hypocalcemia. Mean anticoagulation score after dialysis was 4.8 ± 0.7 for the arterial bubble trap, 4.6 ± 0.8 for the dialyzer and 4.8 ± 0.7 for the venous bubble trap. Serum citrate after dialysis was 158 ± 60 µmol/l. Conclusion: Regional citrate anticoagulation in single-needle dialysis is safe and efficient.

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confidence: 47%

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

Gubenšek¹,

Buturović‐Ponikvar²,

Ponikvar³

2007

Blood Purif

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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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“…The citrate infusion rate (54 mmol/h) used in this study was higher than the rate we used for citrate hemodialysis with calcium‐free dialysate (41 mmol/h) (15) because calcium‐containing infusate was used in HF. Others have used even higher doses of citrate (64–75 mmol/h) in hemodialysis (16,17), especially when calcium‐containing dialysate was used (17).…”

Section: Discussionmentioning

confidence: 93%

Regional Citrate Anticoagulation for Intermittent Predilution Online Hemofiltration

et al. 2009

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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.

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Standard Citrate Versus Sequential Citrate/Anticoagulant‐free Anticoagulation During Hemodialysis: A Randomized Trial

Cited by 21 publications

References 6 publications

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

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

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Regional Citrate Anticoagulation for Intermittent Predilution Online Hemofiltration

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