Trisodium Citrate: An Alternative to Unfractionated Heparin for Hemodialysis Catheter Dwells

Abstract

The use of tunneled hemodialysis catheters, or permcaths, either for temporary dialysis access before arteriovenous fistula or arteriovenous graft maturation or for long-term dialysis access, is associated with increased risk of catheter clotting and infection. Catheter locking solutions are routinely used to maintain patency in these catheters between dialysis sessions. Unfractionated heparin has traditionally been used for this purpose; however, trisodium citrate (also known as sodium citrate or citrate) has recently been shown to be an efficacious alternative to heparin as a locking solution. Citrate exerts both its anticoagulant and antimicrobial properties by chelating calcium to disrupt the normal coagulation pathway and by interfering with the formation of biofilm and the bacterial cell wall. Citrate is at least equivalent to heparin as an anticoagulant and antimicrobial agent for catheter locking, and in some clinical studies citrate was shown to be superior. Two different concentrations of sodium citrate were previously available; however, concerns of safety led to the removal of citrate 46.7% from the United States and Canadian markets in 2000, leaving only citrate 4% available for use as a catheter locking solution. The systemic hypocalcemic effects that were reported with citrate 46.7% have not been observed with citrate 4% in clinical trials, and the risk of systemic anticoagulation and bleeding was shown to be lower than that with unfractionated heparin. In addition, most comparative cost data indicate that citrate is a more cost-effective alternative than heparin; however, costs can vary by institution. Despite inconclusive evidence of clinical superiority, citrate 4% appears to provide a safe and at least equivocal alternative to heparin as a catheter locking agent.

The CLOCK trial, a double‐blinded randomized controlled trial: Trisodium citrate 30% and minocycline 3 mg/mL plus EDTA 30 mg/mL are effective and safe for catheter patency maintenance among CKD 5D patients on hemodialysis

“…In addition, according to results of Liu and colleagues' meta‐analysis (2015), in comparison with heparin, antimicrobial‐containing lock solutions are more effective in the prevention of CRBSI, with citrate‐alone lock solutions resulting in lower levels of CRBSI, bleeding and exit‐site infections episodes . Based upon these findings, TSC seems to be the best option, corroborating the data of other studies . However, a larger comparative trial is needed to confirm this.…”

“…23 Based upon these findings, TSC seems to be the best option, corroborating the data of other studies. 18,[23][24][25] However, a larger comparative trial is needed to confirm this.…”

Citrate Versus Heparin Lock for Hemodialysis Catheters: A Systematic Review and Meta-analysis of Randomized Controlled Trials

“…Nevertheless, this finding is consistent with previous literature. 26 However, because only 2 RCTs with limited case numbers (352 patients, 20,638 catheter-days) met our inclusion criteria, 5,6 results should be interpreted with caution until more large-scale RCTs are available.…”

Comparação entre citrato trissódico e heparina como solução para selo de cateter em pacientes em hemodiálise

“…Citrate has been associated with a reduction in the incidence of bacteremia due to its bactericidal effect at concentrations higher than 23%. 14,15,16,17 Some studies, however, showed no difference regarding citrate or heparin use. 18,19,20 One of such studies, a randomized and controlled one, reported no citrate superiority over heparin; however, the authors attributed such result to the low occurrence of events in both groups (lower than 0.7 bacteremia episodes/1,000 catheters.day).…”