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      Safe Use of Citric Acid-Based Dialysate and Heparin Removal in Postdilution Online Hemodiafiltration

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          Background: Anticoagulation of the blood circuit with heparin is essential for hemodialysis, but exposes patients to several risks (bleeding, thrombocytopenia, etc.). The use of citric acid-based dialysate (CitA-D) allows the reduction of heparin in conventional hemodialysis. We evaluated the feasibility of using CitA-D in postdilution online hemodiafiltration (OL-HDF) and of removing heparin. Methods: We prospectively compared chlorhydric acid-based dialysate with CitA-D in 10 patients treated by OL-HDF. First, we reduced heparin by half the dose and then we totally removed anticoagulation. Results: For all 120 sessions using heparin-free CitA-D, only one clotting episode related to an arteriovenous fistula stenosis was observed. No adverse clinical effect was observed. (Kt/V)<sub>sp</sub>, predialytic serum bicarbonate, calcium, phosphate, parathroid hormone, and β<sub>2</sub>-microglobulin remained the same in all cases. Conclusion: Our data suggest that the use of CitA-D in OL-HDF is safe and allows heparin removal in most patients.

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          Most cited references 15

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          Increased efficiency of hemodialysis with citrate dialysate: a prospective controlled study.

          A bicarbonate dialysate acidified with citrate (CD) has been reported to have local anticoagulant effect. This study examines the effect of CD on dialysis efficiency, measured as eKt/Vurea, and predialysis concentrations of BUN, creatinine, phosphate, and beta-2 microglobulin in chronic dialysis units. Three outpatient chronic hemodialysis units with 142 patients were switched to CD for 6 mo. Using each patient's prior 6 mo on regular bicarbonate dialysate acidified by acetate (AD) as control, eKt/Vurea was compared with that of CD. Follow-up data for 7 mo after the study were collected from about one-half of the participants remaining on CD and the others returned to AD. eKt/Vurea, increased (P < 0.0001) from pre-CD value of 1.51 +/- 0.01 to 1.57 +/- 0.01 with CD. During CD use beta-2 microglobulin levels declined (P = 0.0001) from 28.1 +/- 10.0 to 25.9 +/- 10.0. Similarly, the concentrations of BUN, creatinine, and phosphate also decreased on CD (P < 0.008). In the poststudy period, eKt/Vurea for the patients staying on CD remained unchanged at 1.60 +/- 0.17 versus 1.59 +/- 0.18 (P = NS), whereas in those returning to AD the eKt/Vurea decreased from 1.55 +/- 0.20 to 1.52 +/- 0.17 (P < 0.0001). Data suggest that CD use is associated with increased solute removal.
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            Is Open Access

            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, 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, 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. Conclusion 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. Trial registration NCT00718289
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                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                March 2013
                09 January 2013
                : 34
                : 3-4
                : 336-343
                aHemodialysis Center Henri Küntziger, AURA, and bDepartment of Biophysics, Faculté de Médecine Pierre et Marie Curie, Paris, France
                Author notes
                *Caroline Créput, Centre Henri Küntziger, AURA, 5 rue du Bessin, FR–75015 Paris (France), E-Mail
                345342 Blood Purif 2012;34:336–343
                © 2013 S. Karger AG, Basel

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                Figures: 5, Tables: 4, Pages: 8
                Original Paper


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