HDCN Article Review/Hyperlink

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)