Regional Citrate Anticoagulation during Hemodialysis

Ridel, Christophe; Mercadal, Lucile; Béné, Bernard; Hamani, Abdelaziz; Deray, Gilbert; Petitclerc, Thierry

doi:10.1159/000089652

Cited by 20 publications

(6 citation statements)

References 53 publications

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“…In regional citrate anticoagulation (RCA) , citrate chelates calcium and blocks the coagulation cascade by lowering the ionized calcium level in ECC, which can be further reduced by using a calcium‐free dialysate . RCA is cumbersome and time consuming, given that monitoring of ionized calcium is mandatory to avoid hypo‐ and hypercalcemia.…”

Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under-and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel lowmolecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.Maintaining full patency in the extracorporeal circuit (ECC) during hemodialysis (HD) sessions is a prerequisite for optimal HD quality (1-4). A complex disturbance of the coagulation system is commonly encountered in patients at the terminal stage of chronic kidney disease (CKD), leading to considerable morbidity and mortality (5). Although HD reduces the bleeding risk by the removal of uremic toxins, interaction between blood and artificial surfaces contributes to activate coagulation pathways. This nonphysiological environment leads to clotting on these foreign surfaces which reduces HD efficiency, shortens circuit lifetime, and increases patient blood loss, nursing workload, disposable consumption, and thus the cost of treatment (3,4).Appropriate anticoagulation requires a subtle balance between under-and over-heparinization to prevent ECC clotting and bleeding, respectively. HD patients are prone to prolonged bleeding episodes from dialysis fistula, as well as gastrointestinal and intracranial hemorrhage (5). Conversely, they may develop a prothrombotic status or comorbid conditions requiring oral anticoagulants or antiplatelet agents (1,5). Of interest, the dialysis population represents the only group of patients to receive heparin three times per week, with a potential longterm cumulative effect associated with an increased risk of osteoporosis, aldosterone suppression and hyperkalemia, and a deterioration of lipid profile...

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Section: Resultsmentioning

confidence: 99%

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Kessler¹,

Moureau

Nguyên

2015

Seminars in Dialysis

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“…RCA offers considerable advantages compared to heparin, especially prolonged filter lifetime [1,2,3,4,5,6], reduced complement activation [7,8], oxidative stress [9], and granulocyte [8,9,10,11] and leucocyte [12 ]activation. Additionally, RCA may be used if heparin is contraindicated, as in patients with heparin-induced thrombocytopenia [13] or with a high risk of bleeding [14,15,16,17,18,19]. Furthermore, there has been one non-blinded single-centre randomized controlled trial that found reduced mortality in critically ill patients with acute renal failure and RCA compared to low-molecular-weight heparin [20].…”

Section: Introductionmentioning

confidence: 99%

A Target-Oriented Algorithm for Citrate-Calcium Anticoagulation in Clinical Practice

Strobl¹,

Hartmann²,

Wallner³

et al. 2013

Blood Purif

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Background/Aims: Because of a high monitoring demand and an ensuing need for automation of regional citrate anticoagulation (RCA), a new semi-automated target-oriented algorithm was developed. The aim of this study was the evaluation of its functionality and safety. Methods: Fourteen haemodialysis patients were treated 5 times consecutively with RCA. Samples were drawn pre- and post-infusion once per hour. Electrolytes, blood cell counts, acid-base and coagulation parameters were analyzed. Results: Mean ionized calcium (Ca²⁺) values pre-filter were 0.23 and 0.33 mmol/l in the 0.2 and 0.3 mmol/l target groups, respectively. Extraction ratios for citrate and total calcium through the dialysis filter were constant during the entire treatment (83 and 68%, respectively). Citrate accumulation was avoided. Conclusion: The new algorithm enables safe and accurate RCA. By regulating Ca²⁺ pre-filter using the target-oriented algorithm, the degree of anticoagulation may be easily controlled.

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“…In 2005, we applied this feedback to heparin-free DCB sessions. 2 Citrate was injected at a rate of 0.34 mmol per 100 mL blood flow into the arterial line as suggested by Janssen et al 3 Thirty sessions were performed in ten patients, with the calcium reinjection rate automatically adjusted to ID in order to achieve a calcium balance equivalent to that obtained with dialysate calcium at 1.75 mmol/L. We observed a dramatic decrease in ionized calcium and a doubling of whole blood-activated clotting time prior to calcium reinjection, reflecting effective regional anticoagulation.…”

Section: Adjustment Of Calcium Infusion Rate According To Ionic Dialy...mentioning

confidence: 99%

“…In 2005, we applied this feedback to heparin‐free DCB sessions 2 . Citrate was injected at a rate of 0.34 mmol per 100 mL blood flow into the arterial line as suggested by Janssen et al 3 .…”

Section: Adjustment Of Calcium Infusion Rate According To Ionic Dialy...mentioning

confidence: 99%

Can regional anticoagulation with calcium‐free dialysate be extended to maintenance hemodialysis?

Petitclerc,

Béné

2024

Artificial Organs

Self Cite

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BackgroundRegional anticoagulation in hemodialysis avoids the use of heparin, which is responsible for both hemorrhagic and non‐hemorrhagic complications. Typically, blood is decalcified by injecting citrate into the arterial line of the extracorporeal circuit. Calcium‐free dialysate improves anticoagulation efficacy but requires injection of a calcium‐containing solution into the venous line and strict monitoring of blood calcium levels. Recent improvements have made regional anticoagulation with calcium‐free dialysate safer and easier.Observations(1) Adjusting the calcium injection rate to ionic dialysance avoids the risk of dyscalcemia, thus making unnecessary the monitoring of blood calcium levels. This adjustment could be carried out automatically by the hemodialysis monitor. (2) As calcium‐free dialysate reduces the amount of citrate required, this can be supplied by dialysate obtained from currently available concentrates containing citric acid. This avoids the need for citrate injection and the risk of citrate overload. (3) Calcium‐free dialysate no longer needs the dialysate acidification required for avoiding calcium carbonate precipitation in bicarbonate‐containing dialysate.ConclusionsRegional anticoagulation with calcium‐free dialysate enables an acid‐ and heparin‐free procedure that is more biocompatible and environmentally friendly than conventional bicarbonate hemodialysis. The availability of specific acid‐free concentrates and adapted hemodialysis monitors is required to extend this procedure to maintenance hemodialysis.

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Regional Citrate Anticoagulation during Hemodialysis

Cited by 20 publications

References 53 publications

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

A Target-Oriented Algorithm for Citrate-Calcium Anticoagulation in Clinical Practice

Can regional anticoagulation with calcium‐free dialysate be extended to maintenance hemodialysis?

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