Flanigan MJ, Pillsbury L, Sadewasser G, Lim VS
Regional hemodialysis anticoagulation: hypertonic trisodium
citrate or anticoagulant citrate dextrose-A
Am J Kidney Dis
(Apr) 27:519-524 1996

Hemodialysis generally requires some form of anticoagulation to
prevent clotting in the extracorporeal circuit. While heparin is the
anticoagulant commonly used, its use may be contra-indicated in
patients with a high risk of bleeding. Regional anticoagulation with
tri-sodium citrate has been developed as an alternative to heparin in
these situations. Use of tri-sodium citrate can be associated with
increased ultrafiltration requirements and post-dialysis alkalosis
and hypernatremia. Various manipulations of the composition of the
citrate infusion fluid and the dialysate have been used to minimize
these problems; however, these changes make the procedure more
cumbersome to perform in a routine setting.
ACD, a mixture of dextrose, citric acid and tri-sodium citrate, is
used by blood banks for blood donation and apheresis. This paper
reports the results of a study designed to evaluate the usefulness of
ACD as an alternative to tri-sodium citrate. ACD and tri- sodium
citrate (1.6 M) were used as anticoagulants in consecutive mid-week
treatments for eight chronic hemodialysis patients. Anticoagulant
doses were adjusted to provide activated clotting times 125 - 175% of
the baseline value. A calcium- and magnesium- containing dialysate
was used. Other aspects of the treatments conformed to the patients
routine dialysis prescription.
Both anticoagulants were comparable in terms of preventing dialyzer
clotting, and both were associated with similar levels of
post-dialysis hypernatremia and decreased ionized calcium. While both
anticoagulants produced a post-dialysis metabolic alkalosis, the
degree of alkalosis was less with ACD than with tri-sodium citrate
(delta HCO3 = 10.4 mmol/L for tri-sodium citrate vs 6.6 mmol/L for
ACD). However, ACD-anticoagulation required the infusion of 2.7 L of
fluid compared to 0.2 L of hypertonic tri-sodium citrate to deliver
the same amount of citrate.
Comment: This work demonstrates that regional anticoagulation
can be performed with ACD. Whether or not ACD offers any advantages
over hypertonic tri-sodium citrate is problematic. The reduced degree
of post-dialysis alkalosis with ACD may be desirable; however, the
increased obligatory ultrafiltration may be a problem, particularly in
the acutely ill patients for whom heparin is contra-indicated. While
this study adds one more option for regional citrate anticoagulation,
the procedure remains complicated by the need to make alterations in
the composition of the citrate infusion solution or the dialysate to
minimize their impact on the patient, no matter which protocol is
used.
Richard A. Ward, Ph.D., University of Louisville, Kentucky)