Original investigations
Dialysis therapies
Citrate for long-term hemodialysis: Prospective study of 1,009 consecutive high-flux treatments in 59 patients

https://doi.org/10.1053/j.ajkd.2004.12.002Get rights and content

Background: Regional citrate anticoagulation during hemodialysis is performed in selected patients at highly specialized units. We postulated that routine use of citrate at a long-term dialysis ward is safe and efficient. Methods: During a 2-year period, we studied 1,009 consecutive citrate-anticoagulated high-flux hemodialysis treatments performed in 59 patients at our long-term dialysis ward. We used a simple citrate infusion protocol, calcium-free dialysate, and intravenous calcium substitution. Simple and clear algorithms allowed adjustments of the calcium substitution rate and dialysate settings by the attending nurse. Adverse events; indications for citrate anticoagulation; clotting; technical data; blood ionized calcium, sodium, and potassium levels; and acid-base homeostasis were analyzed prospectively. Results: Of the treatments, 99.6% were accomplished successfully. Two adverse events were attributed to citrate use. Overall, ionized calcium levels were stable during the procedures and electrolyte and acid-base balances were well controlled. The use of central venous catheters for dialysis was associated with paradoxical behavior of ionized calcium levels (increasing blood ionized calcium levels despite decreased calcium infusion). Anticoagulation was excellent. Conclusion: Routine use of citrate anticoagulation in the setting of a long-term hemodialysis ward is safe and efficient. Measured ionized calcium levels should be interpreted with care if central venous catheters are used for vascular access because they could be biased by recirculation.

Section snippets

Study design and setting

This is a prospective, longitudinal, observational study of the first 1,009 citrate-anticoagulated high-flux hemodialysis treatments performed during a 2-year period at a long-term hemodialysis ward (12 places, 3 shifts) of a tertiary-care center.

Outcome measures

Primary outcome measures were the feasibility and safety (in terms of adverse events, calcium homeostasis, and electrolyte and acid-base control) of citrate anticoagulation during high-flux hemodialysis in the setting of a maintenance hemodialysis

Clinical results

One thousand five of 1,009 treatments were accomplished successfully. Citrate anticoagulation was tolerated well, and only 2 adverse events related to citrate anticoagulation were observed (0.2%). Both events were caused by handling errors at the beginning of our experience (treatments 6 and 9). One patient reported oral paresthesia when the 5-fold citrate dose was infused erroneously for 10 minutes and ionized calcium levels decreased from 2.36 mEq/L (1.18 mmol/L) to 1.56 mEq/L (0.78 mmol/L).

Discussion

We show in a large prospective study that routine use of regional citrate anticoagulation in the setting of a maintenance hemodialysis ward is practicable, efficient, and safe. One thousand five of 1,009 consecutive citrate anticoagulated high-flux hemodialysis treatments (99.6%) were accomplished successfully. Citrate-associated adverse events were extremely rare (0.2%) and were caused by handling errors in the early implementation phase (treatments 6 and 9). Perturbations of sodium and

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  • Originally published online as doi:10.1053/j.ajkd.2004.12.002 on January 26, 2005.

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