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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 533-534
Regional citrate anticoagulation for hemodialysis: A safe and efficient method

1 Department of Nephrology, Sfax University Hospital, Sfax, Tunisia
2 Department of Biochemistry, Sfax University Hospital, Sfax, Tunisia

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Date of Web Publication26-Apr-2010

How to cite this article:
Jarraya F, Mkawar K, Kammoun K, Hdiji A, Yaich S, Kharrat M, Charfeddine K, Hmida MB, Mahfoudh H, Ayedi F, Hachicha J. Regional citrate anticoagulation for hemodialysis: A safe and efficient method. Saudi J Kidney Dis Transpl 2010;21:533-4

How to cite this URL:
Jarraya F, Mkawar K, Kammoun K, Hdiji A, Yaich S, Kharrat M, Charfeddine K, Hmida MB, Mahfoudh H, Ayedi F, Hachicha J. Regional citrate anticoagulation for hemodialysis: A safe and efficient method. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Aug 12];21:533-4. Available from: https://www.sjkdt.org/text.asp?2010/21/3/533/62710
To the Editor,

Regional citrate anticoagulation (RCA) was proposed by Pinnik et al as an alternative to heparin for intermittent hemodialysis (HD), [1] was first used by Morita et al. in 1961. [2] More recently, it is used for continuous hemodialysis [3] in high risk bleeding patients. Citrate achieves anticoagulation by forming complexes with io­nized calcium. During HD, the citrate effect is most likely confined to the extra corporeal sys­tem because about 60% of the formed citrate complexes are removed from the blood by the dialyzer. Citrate that leaves the dialyzer and enters the patient's circulation is rapidly meta­bolized in the tricarboxylic acid pathway, pre­dominantly in the liver and skeletal muscle. [4] Hypertonic trisodium citrate (TSC) was mainly used in the literature. It seems to be efficient with no systemic anticoagulation. However, it can result in hypernatremia or hypercalcemia. In addition, the combination of TSC and bicar­bonate dialysate produces a profound metabo­lic alkalosis. [5]

We report our experience with 26 (17 men, mean age was 52 ± 13 years and mean dialysis duration was 54 ± 43 months) regular HD pa­tients without risk for bleeding over 26 hemo­dialysis sessions. All hemodialysis sessions lasted four hours, and were carried out with acetate dialysate using Gambro AK 95 and Fresenius 4008B monitors and disposable po­lysulfone (FreseniusTM) dialyzers. RCA was performed by continuous infusion of sterile 510 mM TSC in the arterial line at a rate of 0.68 mmol/min. A calcium- and magnesium­free dialysate containing 29.5 mmol acetate af­ter 35-fold dilution was used. To correct the induced calcium loss, calcium-chloride was in­fused in the venous line at rates of 0.18 mmol/ min. All clinical manifestations were noted during the dialysis session. Laboratory check­up was made at the start, at 2 hours, between citrate injection site and dialyzer (arterial), bet­ween calcium injection site and patient (ve­nous) and at the end of the session.

Hypotension was noted in 4 (15%) patients and hypocalcaemia related clinical manifesta­tions in 3 (12%) cases. Although there was no total dialyzer clotting, partial clotting was no­ted in 5(19%) cases. Premature dialysis session discontinuation was required for 3 patients due to recurrent hypotension one, clinical manifes­tations attributed to hypocalcemia but not con­firmed at blood analysis in another, and into­lerance to acetate and or citrate in a third one. Biochemical tests showed neither alterations of sodium nor of calcium blood levels at the end of the dialysis session. Serum bicarbonate increased at the end of dialysis sessions but without reaching an alkalemic state. Activated partial thromboplastin time (APTT) increased after citrate administration (T2a: 124 ± 5 min) and return to a normal range (T2v: 28 ± 7 min) after calcium chloride infusion. At the end of dialysis session, the mean APTT was at 27 ± 3 min (matches the baseline values). There no more nursing time spent while using this method of anticoagulation than the regular HD with heparin.

Our study shows that RCA with TSC was a safe and simple method for anticoagulation in our HD patients as shown by others without compromising efficiency of dialysis or more inconvenience to staff in comparison to stan­ dard HD. [6],[7],[8],[9],[10],[11] Many protocols required the use of a dialysate with or without calcium. [12],[13],[14] We support the use of calcium-free dialysate since it is more securable to use with RCA. We be­lieve that RCA can be considered for chronic HD patients who are not only at risk of blee­ding if they have pre-morbid vascular abnor­malities, such as intestinal arterio-venous mal­formations, diabetic proliferate retinopathy, malignant hypertension, and polycystic kidney disease in addition to heparin induced throm­ bocytopenia. [10]

   Acknowledgment Top

This work was supported by a grant from Hedi Chaker Hospital, Sfax University Hos­pital, Tunisia. We are grateful to Dr. Philippe Moriniere for his advices.

   References Top

1.Pinnick RV, Wiegmann TB, Diederich DA. Regional citrate anticoagulation for hemodialysis in the patient at high risk for bleeding. New Engl J Med 1983;308:258-61.  Back to cited text no. 1  [PUBMED]    
2.Morita Y, Johnson RW, Dorn RE, Hall D. Regional anticoagulation during hemodialysis using citrate. Am J Med Sci 1961;242:32-43.  Back to cited text no. 2      
3.Gabutti L, Marone C, Colucci G, Duchini F, Schonholzer C. Citrate anticoagulation in conti­nuous venovenous hemodiafiltration: A metabolic challenge. Intensive Care Med 2002;28:1419-25.  Back to cited text no. 3      
4.Von Brecht JH, Flanigan MJ, Freeman RM, Lim VS. Regional anticoagulation: Hemodialysis with hypertonic trisodium citrate. Am J Kidney Dis 1986; 8:196-201  Back to cited text no. 4      
5.Collart F, Wens R, Dratwa M. Regional anti­coagulation with sodium citrate: Chronic utili­zation in the hemodialysis patient. Nephrologie 1993;14:151-4.  Back to cited text no. 5  [PUBMED]    
6.Unver B, Sunder-Plassmann G, Horl WH, Apsner R. Long-term citrate anticoagulation for high-flux haemodialysis in a patient with heaprin-induced thrombocytopenia type II. Acta Med Austriaca 2002;29:146-8.  Back to cited text no. 6      
7.Faber LM, de Vries PM, Oe PL, van der Meulen J, Donker AJ. Citrate haemodialysis. Neth J Med 1990;37:219-24.  Back to cited text no. 7  [PUBMED]    
8.Brecht JH, Flanigan MJ, Freeman RM, Lim VS. Regional anticoagulation: Hemodialysis with hyper­tonic trisodium citrate. Am J Kidney Dis 1986;8: 196-201.  Back to cited text no. 8  [PUBMED]    
9.Van Der Meulen J, Janssen MJ, Langendijk PN, Bouman AA, Oe PL. Citrate anticoagulation and dialysate with reduced buffer content in chronic hemodialysis. Clin Nephrol 1992;37:36-41.  Back to cited text no. 9      
10.Janssen MJ, Huijgens PC, Bouman AA, Oe PL, Donker AJ, Van der Meulen J. Citrate versus heparin anticoagulation in chronic haemodialysis patients. Nephrol Dial Transplant 1993;8:1228-33.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Flanigan MJ, Pillsbury L, Sadewasser G, Lim VS. Regional hemodialysis anticoagulation: hyper­tonic trisodium citrate or anticoagulant citrate­dextrose-A. Am J Kidney Dis 1996;27:519-24.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Janssen MJ, Huijgens PC, Bouman AA, Oe PL, Van Der Meulen J. Citrate anticoagulation and divalent cations in hemodialysis. Blood Purif 1994;12:308-16.  Back to cited text no. 12  [PUBMED]    
13.Wiegmann TB, MacDougall ML, Diederich DA. Long-term comparisons of citrate and heparin as anticoagulants for hemodialysis. Am J Kidney Dis 1987;9:430-5.  Back to cited text no. 13  [PUBMED]    
14.Evenepoel P, Maes B, Vanwalleghem J, Kuypers D, Messiaen T, Vanrenterghem Y. Regional citrate anticoagulation for hemodialysis using a conventional calcium-containing dialysate. Am J Kidney Dis 2002;39:315-23.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  

Correspondence Address:
Faical Jarraya
Department of Nephrology, Sfax University Hospital, Sfax
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Source of Support: None, Conflict of Interest: None

PMID: 20427885

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