Avoidance of systemic anticoagulation during intermittent haemodialysis with heparin-grafted polyacrilonitrile membrane and citrate-enriched dialysate: a retrospective cohort study

Abstract

BackgroundSince October 2010, the combination of a heparin-grafted polyacrilonitrile (AN69ST) membrane with a 0.80 mmol/L citric acid-containing dialysate is routinely used in our centre for intermittent haemodialysis, without systemic anticoagulation, in critically ill patients with increased bleeding risk. The primary outcome of this retrospective cohort study was to assess the development of circuit clotting during these dialysis procedures. Secondly, we assessed the impact of clotting on treatment duration, the incidence rate of coagulation-induced retransfusion failure and the association of patient and dialysis characteristics with the occurrence of clotting.MethodsDialysis and patient data on consecutive intermittent haemodialysis procedures, performed at the Intensive Care Unit of Universitair Ziekenhuis Brussel between October 2010 and March 2012, were retrospectively reviewed. We used descriptive statistics as well as a random effects logit model with patient identity as a panel variable to assess associations.ResultsOf a total of 309 treatments combining a heparin-grafted AN69ST membrane and a 0.8 mmol/L citric acid-enriched dialysate in 94 patients, circuit clotting was reported in 17.5% (95% CI 13.2% to 21.7%; N = 54), and in 19% (95% CI 13.6% to 24.4%; N = 40) of sessions with prescribed treatment time ≥ 4 hours (N = 210). Clotting shortened treatment time in 15.2% (95% CI 11.4% to 19.7%; N = 47) of sessions by a median of 55 (IQR 20 to 80) minutes. Complete clotting of the circuit with inability for retransfusion occurred in 4.2% (95% CI 2.2% to 7.0%; N = 13) of sessions. Circuit coagulation was not associated with APACHE II score, patient age, gender, number of treatments, type of vascular access or ultrafiltration rate.ConclusionIntermittent haemodialysis without systemic anticoagulation combining a heparin-grafted AN69ST dialyzer with a citrate-enriched dialysate favourably compares as to clotting complications with the published outcomes of anticoagulation-free intermittent haemodialysis strategies using saline flushes, heparin-coated dialyzer in combination with regular dialysate or regional citrate anticoagulation with calcium supplemented dialysate. The incidence of circuit clotting in our cohort appears to be higher than previously reported for regional citrate anticoagulation with a calcium-free dialysate.

Inpatient citrate-based hemodialysis in pediatric patients

“…These authors recorded a similar incidence of early HD termination due to severe clotting but did not report any details on overall circuit loss [12]. The circuit loss seen in our study is comparable to that in published adult studies using citrate-based dialysate [13]. It is possible that we noted a higher thrombosis rate as we charted any circuit clot and not just dialyzer clotting.…”

The Effect of Citrate on Clot Formation, Dialyzer Reuse, and Anemia in Hemodialysis Patients

“…Only a few studies comparing acetate to CD have been performed. Francois et al [8] reported the avoidance of systemic heparin during intermittent HD while combining a heparin-grafted AN 69 dialyzer with CD in 81% of sessions. One large prospective study in 277 HD patients by Sands et al [9] demonstrated that CD can reduce heparin dosage by 33%.…”

Comparison of the AN69ST Membrane versus Citrate-Enriched Dialysate on Clotting Events during Hemodialysis without Systemic Anticoagulation

“…In contrast, our study described the outcomes of HD sessions using only an AN69ST membrane or only a citrate- enriched dialysate. We found that few sessions needed to be terminated prematurely: that is, 8.7% of patients treated with citrate-enriched dialysate compared to 12.7% of patients treated with AN69ST membrane, when compared to that reported by François et al [16]. …”