Citrate- vs. acetate-based dialysate in bicarbonate haemodialysis: consequences on haemodynamics, coagulation, acid-base status, and electrolytes.
BACKGROUND
A concentrate for bicarbonate haemodialysis acidified with citrate instead of acetate has been marketed in recent years. The small amount of citrate used (one-fifth of the concentration adopted in regional anticoagulation) protects against intradialyser clotting while minimally affecting the calcium concentration. The aim of this study was to compare the impact of citrate- and acetate-based dialysates on systemic haemodynamics, coagulation, acid-base status, calcium balance and dialysis efficiency.


METHODS
In 25 patients who underwent a total of 375 dialysis sessions, an acetate dialysate (A) was compared with a citrate dialysate with (C+) or without (C) calcium supplementation (0.25 mmol/L) in a randomised single-blind cross-over study. Systemic haemodynamics were evaluated using pulse-wave analysis. Coagulation, acid-base status, calcium balance and dialysis efficiency were assessed using standard biochemical markers.


RESULTS
Patients receiving the citrate dialysate had significantly lower systolic blood pressure (BP) (-4.3 mmHg, p < 0.01) and peripheral resistances (PR) (-51 dyne.sec.cm-5, p < 0.001) while stroke volume was not increased. In hypertensive patients there was a substantial reduction in BP (-7.8 mmHg, p < 0.01). With the C+ dialysate the BP gap was less pronounced but the reduction in PR was even greater (-226 dyne.sec.cm-5, p < 0.001). Analyses of the fluctuations in PR and of subjective tolerance suggested improved haemodynamic stability with the citrate dialysate. Furthermore, an increase in pre-dialysis bicarbonate and a decrease in pre-dialysis BUN, post-dialysis phosphate and ionised calcium were noted. Systemic coagulation activation was not influenced by citrate.


CONCLUSIONS
The positive impact on dialysis efficiency, acid-base status and haemodynamics, as well as the subjective tolerance, together indicate that citrate dialysate can significantly contribute to improving haemodialysis in selected patients.
Gabutti
Luca
L
Division of Nephrology, Ospedale la Carità, Via Ospedale, 6600 Locarno, Switzerland. luca.gabutti@eoc.ch
Lucchini
Barbara
B
Marone
Claudio
C
Alberio
Lorenzo
L
Burnier
Michel
M
D000085:Acetates / Q000008:administration & dosage / Q000494:pharmacology*; D000136:Acid-Base Equilibrium / Q000187:drug effects*; D000368:Aged; D000369:Aged, 80 and over; D001639:Bicarbonates / Q000008:administration & dosage; D001777:Blood Coagulation / Q000187:drug effects*; D001806:Blood Urea Nitrogen; D002118:Calcium / Q000008:administration & dosage / Q000097:blood / Q000494:pharmacology; D019343:Citric Acid / Q000008:administration & dosage / Q000494:pharmacology*; D018592:Cross-Over Studies; D004573:Electrolytes / Q000097:blood*; D005260:Female; D015312:Hemodialysis Solutions / Q000494:pharmacology*; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010710:Phosphates / Q000097:blood; D006435:Renal Dialysis / Q000379:methods*; D016037:Single-Blind Method
D000085:Acetates; D001639:Bicarbonates; D004573:Electrolytes; D015312:Hemodialysis Solutions; D010710:Phosphates; D019343:Citric Acid; D002118:Calcium