Citrate- vs. acetate-based dialysate in bicarbonate haemodialysis: consequences on haemodynamics, coagulation, acid-base status, and electrolytes

Abstract

BackgroundA concentrate for bicarbonate haemodialysis acidified with citrate instead of acetate has been marketed in recent years. The small amount of citrate used (one-fifth of the concentration adopted in regional anticoagulation) protects against intradialyser clotting while minimally affecting the calcium concentration. The aim of this study was to compare the impact of citrate- and acetate-based dialysates on systemic haemodynamics, coagulation, acid-base status, calcium balance and dialysis efficiency.MethodsIn 25 patients who underwent a total of 375 dialysis sessions, an acetate dialysate (A) was compared with a citrate dialysate with (C+) or without (C) calcium supplementation (0.25 mmol/L) in a randomised single-blind cross-over study. Systemic haemodynamics were evaluated using pulse-wave analysis. Coagulation, acid-base status, calcium balance and dialysis efficiency were assessed using standard biochemical markers.ResultsPatients receiving the citrate dialysate had significantly lower systolic blood pressure (BP) (-4.3 mmHg, p < 0.01) and peripheral resistances (PR) (-51 dyne.sec.cm-5, p < 0.001) while stroke volume was not increased. In hypertensive patients there was a substantial reduction in BP (-7.8 mmHg, p < 0.01). With the C+ dialysate the BP gap was less pronounced but the reduction in PR was even greater (-226 dyne.sec.cm-5, p < 0.001). Analyses of the fluctuations in PR and of subjective tolerance suggested improved haemodynamic stability with the citrate dialysate. Furthermore, an increase in pre-dialysis bicarbonate and a decrease in pre-dialysis BUN, post-dialysis phosphate and ionised calcium were noted. Systemic coagulation activation was not influenced by citrate.ConclusionThe positive impact on dialysis efficiency, acid-base status and haemodynamics, as well as the subjective tolerance, together indicate that citrate dialysate can significantly contribute to improving haemodialysis in selected patients.Trial registrationClinicalTrials.gov NCT00718289

Effects of Citrate Acid Concentrate (Citrasate®) on Heparin N Requirements and Hemodialysis Adequacy: A Multicenter, Prospective Noninferiority Trial

“…Gabutti et al [6] demonstrated significant reduction in systolic blood pressure (SBP) and peripheral resistance with the use of CD (2.4 mEq/l citrate, 0.3 mEq/l acetate) when compared to standard acetate containing bicarbonate dialysate (0 mEq/l citrate, 3.0 mEq/l acetate) in a randomized single blind crossover study of 25 patients. SBP decreased 4.3 mm Hg (p < 0.01), peripheral resistance decreased 51 dyn·s·cm –5 , and stroke volume remained stable.…”

“…Predialysis serum bicarbonate increased 0.9 mEq/l with CD (20.6 ± 2.5 mEq/l standard dialysate; 21.5 ± 2.8 mEq/l CD; p < 0.01). These data suggest that CD is more biocompatible and physiologic than standard acetate containing bicarbonate dialysate, with positive effects on hemodynamics and acid-base balance in addition to improved dialysis efficacy [6] and heparin reduction. …”

“…There have been no safety issues reported with CD [2,5,6]. The major potential concern is the possibility of decreasing iCa.…”

“…CD is FDA-approved [1] and has been demonstrated to be safe and effective [2]. Published reports suggest that CD may improve dialysis adequacy [Kt/V (K = clearance, t = time on dialysis and V = volume of distribution)] [2,5,6], decrease hemodialysis heparin requirements [7,8,9], and increase dialyzer reuse [10], presumably due to nonsystemic anticoagulant effects in the dialyzer. These studies, however, are limited by their small sample size and/or lack of adequate controls.…”

Líquido dializante con citrato frente a acetato en pacientes en hemodiafiltración on-line de alta eficacia: parámetros a estudio

“…Además de estos beneficios, consigue una mejoría del equilibrio ácido-base dado su efecto tampón y una mayor tolerancia a la sesión de diá-lisis consecuencia de una mayor estabilidad cardiovascular 7 …”