title: Avoidance of systemic anticoagulation during intermittent haemodialysis with heparin-grafted polyacrilonitrile membrane and citrate-enriched dialysate: a retrospective cohort study.
abstract: BACKGROUND
  Since October 2010, the combination of a heparin-grafted polyacrilonitrile (AN69ST) membrane with a 0.80 mmol/L citric acid-containing dialysate is routinely used in our centre for intermittent haemodialysis, without systemic anticoagulation, in critically ill patients with increased bleeding risk. The primary outcome of this retrospective cohort study was to assess the development of circuit clotting during these dialysis procedures. Secondly, we assessed the impact of clotting on treatment duration, the incidence rate of coagulation-induced retransfusion failure and the association of patient and dialysis characteristics with the occurrence of clotting.
  
  
  METHODS
  Dialysis and patient data on consecutive intermittent haemodialysis procedures, performed at the Intensive Care Unit of Universitair Ziekenhuis Brussel between October 2010 and March 2012, were retrospectively reviewed. We used descriptive statistics as well as a random effects logit model with patient identity as a panel variable to assess associations.
  
  
  RESULTS
  Of a total of 309 treatments combining a heparin-grafted AN69ST membrane and a 0.8 mmol/L citric acid-enriched dialysate in 94 patients, circuit clotting was reported in 17.5% (95% CI 13.2% to 21.7%; N = 54), and in 19% (95% CI 13.6% to 24.4%; N = 40) of sessions with prescribed treatment time ≥ 4 hours (N = 210). Clotting shortened treatment time in 15.2% (95% CI 11.4% to 19.7%; N = 47) of sessions by a median of 55 (IQR 20 to 80) minutes. Complete clotting of the circuit with inability for retransfusion occurred in 4.2% (95% CI 2.2% to 7.0%; N = 13) of sessions. Circuit coagulation was not associated with APACHE II score, patient age, gender, number of treatments, type of vascular access or ultrafiltration rate.
  
  
  CONCLUSIONS
  Intermittent haemodialysis without systemic anticoagulation combining a heparin-grafted AN69ST dialyzer with a citrate-enriched dialysate favourably compares as to clotting complications with the published outcomes of anticoagulation-free intermittent haemodialysis strategies using saline flushes, heparin-coated dialyzer in combination with regular dialysate or regional citrate anticoagulation with calcium supplemented dialysate. The incidence of circuit clotting in our cohort appears to be higher than previously reported for regional citrate anticoagulation with a calcium-free dialysate.
authors.affiliation: Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Jette, Belgium. karlien.francois@uzbrussel.be.
authors.forename: Karlien
authors.initials: K
authors.lastname: François
authors.forename: Karl Martin
authors.initials: KM
authors.lastname: Wissing
authors.forename: Rita
authors.initials: R
authors.lastname: Jacobs
authors.forename: Dries
authors.initials: D
authors.lastname: Boone
authors.forename: Kristine
authors.initials: K
authors.lastname: Jacobs
authors.forename: Christian
authors.initials: C
authors.lastname: Tielemans
mesh_terms: D000180:Acrylic Resins / Q000008:administration & dosage*; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage; D001777:Blood Coagulation / Q000187:drug effects / Q000502:physiology; D019343:Citric Acid / Q000008:administration & dosage*; D015331:Cohort Studies; D015314:Dialysis Solutions / Q000008:administration & dosage*; D005260:Female; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D008297:Male; D008567:Membranes, Artificial; D008875:Middle Aged; D006435:Renal Dialysis / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000180:Acrylic Resins; D000925:Anticoagulants; D015314:Dialysis Solutions; D008567:Membranes, Artificial; C010504:polyacrylonitrile; D019343:Citric Acid; D006493:Heparin