title: Regional citrate anticoagulation is safe in intermittent high-flux haemodialysis treatment of children and adolescents with an increased risk of bleeding.
abstract: BACKGROUND
  Regional citrate anticoagulation (RCA) is strongly recommended for adults with an increased risk of bleeding complications. The objective of this retrospective analysis was to evaluate an RCA protocol concerning feasibility and safety in intermittent high-flux haemodialysis (iHD) treatment in children and adolescents.
  
  
  METHODS
  Eighteen children and adolescents aged 5-17 years (median 15 years) underwent 74 iHD treatment sessions with RCA. Twelve of 18 patients presented with overt local or diffuse haemorrhage before beginning the HD sessions, and six had an increased risk of haemorrhagic complications. Forty children on acute haemodialysis with general heparin anticoagulation, matched for bleeding risk, age and body surface area, served as a control group. Citrate 3% solution was begun with 3.3% blood flow rate, and calcium gluconate 10% substitution was started with 0.4% of blood flow rate. Citrate flow was adapted to achieve a post-filter ionized calcium of ≤0.30 mmol/L; calcium substitution was adapted to maintain the patients' serum calcium levels within the physiological range. Calcium-free dialysis fluid was used. The blood flow rate ranged from 3 to 5 mL per minute and kilogram body weight.
  
  
  RESULTS
  Regional anticoagulation was successfully achieved within the extracorporeal blood circuit, while the coagulation of all 18 patients remained within physiological parameters. No adverse effects of RCA were observed. In all 18 children, neither new haemorrhage nor worsening of the bleeding situation occurred, and in 10/12 patients, bleeding stopped during dialysis with RCA. In contrast, one-third of the control group developed new haemorrhagic complications or presented with worsening of pre-existing bleeding during haemodialysis (P = 0.006).
  
  
  CONCLUSIONS
  RCA is feasible, safe and effective in paediatric intermittent haemodialysis treatment.
authors.affiliation: Department of Paediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany. kreuzer.martin@mh-hannover.de
authors.forename: Martin
authors.initials: M
authors.lastname: Kreuzer
authors.forename: Klaus-Eugen
authors.initials: KE
authors.lastname: Bonzel
authors.forename: Rainer
authors.initials: R
authors.lastname: Büscher
authors.forename: Gisela
authors.initials: G
authors.lastname: Offner
authors.forename: Jochen H H
authors.initials: JH
authors.lastname: Ehrich
authors.forename: Lars
authors.initials: L
authors.lastname: Pape
mesh_terms: D000293:Adolescent; D000925:Anticoagulants / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D019343:Citric Acid / Q000627:therapeutic use*; D005260:Female; D006470:Hemorrhage / Q000517:prevention & control*; D006801:Humans; D008297:Male; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants; D019343:Citric Acid