Citrate for long-term hemodialysis: prospective study of 1,009 consecutive high-flux treatments in 59 patients.
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.


CONCLUSIONS
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.
Apsner
Robert
R
Department of Medicine III, Division of Nephrology and Dialysis, University of Vienna, Vienna, Austria. robertapsner@hotmail.com
Buchmayer
Heidi
H
Gruber
Diego
D
Sunder-Plassmann
Gere
G
D000136:Acid-Base Equilibrium; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D002118:Calcium / Q000008:administration & dosage / Q000378:metabolism; D002951:Citrates / Q000008:administration & dosage* / Q000009:adverse effects / Q000097:blood; D004334:Drug Administration Schedule; D005260:Female; D015312:Hemodialysis Solutions / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced; D006706:Homeostasis; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000139:chemically induced; D010292:Paresthesia / Q000139:chemically induced; D011446:Prospective Studies; D006435:Renal Dialysis / Q000295:instrumentation / Q000379:methods*; D000077559:Sodium Citrate; D016896:Treatment Outcome; D014882:Water-Electrolyte Balance
D000925:Anticoagulants; D002951:Citrates; D015312:Hemodialysis Solutions; D000077559:Sodium Citrate; D002118:Calcium