Regional citrate anticoagulation for hemodialysis using a conventional calcium-containing dialysate

Regional citrate anticoagulation is currently a frequently applied technique for hemodialysis patients at increased risk of bleeding. Most experience exists with isotonic citrate in combination with a calcium-free dialysate and separate substitution with calcium chloride. This method is effective, but rather cumbersome and laborious. In search for a less demanding, but equally safe and effective technique, we performed 203 double-needle hemodialysis sessions in 45 patients at high risk of bleeding using regional anticoagulation with hypertonic trisodium citrate (TSC) and a conventional calcium-containing dialysate. At the start of dialysis, citrate was infused at a rate of 75 mL/h; adjustments were made during dialysis according to the degree of anticoagulation and level of ionized calcium within the systemic circuit. The efficacy and short-term safety of regional anticoagulation with TSC as compared with heparin anticoagulation was ascertained in a cohort of 19 stable hemodialysis patients. Systemic anticoagulation did not occur, and plasma-ionized calcium remained on a stable level. Manifestations of citrate toxicity or hypocalcemia were not observed. Clotting within the dialyzer was noted in 18 of the 203 sessions (8.87%) and resulted in early termination of dialysis in only 3 cases (1.48%). In conclusion, the use of hypertonic TSC and a conventional calcium-containing dialysate was shown to be safe and effective. The risk of clotting of the extracorporeal circuit is limited and outweighed by the advantage of reduced procedural complexity. Compared with the use of a calcium-free dialysate, the number of analyses can be reduced substantially, making this method financially attractive.