Citrate anticoagulation

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Intravenous literature: Wright, S., Steinwandel, U. and Ferrari, P. (2010) Citrate anticoagulation during long-term haemodialysis. Nephrology. Nov 3. [Epub ahead of print]

Abstract:

Aim: To assess safety and efficacy of a newly developed protocol of citrate-anticoagulation for routine use in haemodialysis patients.

Background: Haemodialysis with regional citrate anticoagulation in patients with contraindications for heparin is increasingly performed in the US and Europe. Most published protocols use trisodium citrate, which is not readily available in Australia. We established a protocol for citrate-anticoagulation in haemodialysis using Acid Citrate Dextrose solution A (ACDA), which is approved for apheresis procedures in Australia.

Methods: Systemic and post-filter blood ionised calcium, serum sodium and bicarbonate and dialyser clotting score were analysed prospectively in 14 patients undergoing 150 consecutive haemodialysis treatments with citrate anticoagulation using calcium-free dialysate. A simple algorithm allowed the attending nurse to adjust citrate infusion (to maintain post-filter ionised calcium at 0.2-0.3mmol/l) and intravenous calcium substitution. Scheduled dialysis time was 4 hours, point-of care monitoring of blood ionised calcium during dialysis was done at time 0, 15, 60, 120 and 240 minutes.

Results: ACDA infusion rates of 300ml/h were used in the first 52 treatments, but resulted in high dialyser clotting score and 6% of treatments discontinued due to complete clotting. Thereafter, ACDA infusion rate was increased to 350ml/h, with all 98 subsequent treatments completed successfully. Ionised calcium levels were stable during all procedures post-dialysis serum sodium averaged 135 ± 3mmol/l and bicarbonate 23.8 ± 2mmol/l.

Conclusion: Routine use of citrate anticoagulation in the setting of a long-term haemodialysis unit is safe and efficient. Point-of-care measurements of ionised calcium levels are critical to safely and successfully perform citrate anticoagulation.

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