Citrate Anticoagulation for Postdilutional Online Hemodiafiltration with Calcium-Containing Dialysate and Infusate: Significant Clotting in the Venous Bubble Trap

Abstract

Background The aim of this prospective clinical study was to assess safety and antithrombotic efficacy of a regional citrate anticoagulation protocol for postdilutional online hemodiafiltration (HDF) with calcium-containing dialysate and infusate. Methods Nineteen postdilutional online HDF procedures with citrate anticoagulation were performed in 9 end-stage renal disease patients. Calcium-containing (1.25 mmol/L) dialysate/infusate, 15% (0.51 mol/L) trisodium citrate and 1 mol/L calcium chloride (when necessary) were used; the blood flow was 300 ml/min. Antithrombotic effect was assessed visually after HDF at 3 points: the dialyzer, arterial bubble trap, and venous bubble trap, using a score of 5 (excellent anticoagulation) to 1 (total clotting). The study was terminated prematurely due to frequent clotting in the venous bubble trap. Results The mean duration of HDF was 4.3 ± 0.9 hours; infusion volume was 13 ± 2 L. Almost half of the HDF procedures (9/19, 47%) were completed with some difficulty: in 1 case (1/19, 5%) there was total system clotting; in the other 8 cases, system clotting was threatening and dialysis was terminated prematurely, but in only 4/19 cases (21%) prior to 4-hour duration. The main point of clot formation was the venous bubble trap (score 2.6 ± 1.0), while anticoagulation was very good at the dialyzer (4.0 ± 1.2) and excellent at the arterial bubble trap (4.8 ± 0.9). No side effects were noted, and metabolic consequences were moderate. Conclusions Regional citrate anticoagulation using calcium-containing dialysate/infusate during postdilutional online hemodiafiltration results in a high incidence of venous bubble trap clotting.

Heparin albumin priming in a clinical setting for hemodialysis patients at risk for bleeding

“…The use of regional citrate anticoagulation (RCA) is common in CVVHD . There are few reports of RCA used in IHD . Using RCA needs surveillance and calculation of citrate and ionized calcium (Ca) doses, fluid amount, magnesium, potassium and change in pH.…”

Regional Citrate Anticoagulation for Intermittent Predilution Online Hemofiltration

“…This is, to our knowledge, the first report on a regional citrate anticoagulation protocol for intermittent online HF. It is well known that citrate anticoagulation protocols need to be adapted for different dialysis procedures: hemodialysis (13), HF or hemodiafiltration (HDF) (14) in their intermittent as well as continuous settings. Unexpected obstacles can be encountered during such modifications; for example, we have reported significant clotting in the venous bubble trap in case of HDF with calcium‐containing dialysate/infusate (14).…”

Anticoagulation régionale des circuits extracorporels par le citrate

“…Une concentration d'iCa-patient plus basse (0,9-1,1 mmol/l) est possible si l'affection sous-jacente s'accompagne d'une hypocalcémie (rhabdomyolyse, pancréatite aiguë, hypocalcémie toxique [22]). Les solutions de dialysat ou de dilution ne doivent pas contenir de calcium, au risque de favoriser la thrombose du filtre par réactivation de la coagulation, ou de nécessiter une majoration des doses infusées de citrate, exposant au risque d'accumulation [23,24]. En revanche, les solutions de réinjection peuvent contenir du calcium, mais doivent être réinjectées par la branche veineuse au plus près du patient pour ne pas réacti-ver la coagulation dans le circuit.…”