Regional citrate anticoagulation protocol suitable for intermittent hemodialysis and post-dilution hemodiafiltration

Aims: Regional citrate anticoagulation (RCA) during intermittent hemodialysis (iHD) effectively prevents circuit clotting without systemic anticoagulation and is especially beneficial for patients at increased bleeding risk. The performance of RCA under different iHD modes is not well documented. Materials and methods: We retrospectively studied all consecutive iHD sessions with our RCA protocol during a 3-year period. We compared low-flux iHD, high-flux iHD, and online post-dilution hemo-diafiltration (oHDF) with regard to flow rates, calcium changes, metabolic outcomes, and complications. We used a calcium-free dialysate, concentrated sodium citrate (0.5 M), and calcium chloride substitution (0.5 M). Several safety measures were implemented to prevent human errors. Results: We performed 111 RCA treatments in 66 cases. Seven sessions were prematurely stopped due to malfunctioning vascular access or pre-existing severe hypotension. The other 104 treatments (94%) consisting of 28 low-flux iHD, 31 high-flux iHD, and 45 oHDF were completed without clotting or complications. The protocol settings were used without adaptations in 75% of low-flux iHD, 93% of high-flux iHD, and 84% of oHDF sessions. Minor adjustments of the calcium flow rate were made within the first 2 hours. We did not observe any clinically relevant differences between the three modes regarding flow rates, systemic iCa, post-filter iCa, pH, or bicarbonate levels. Conclusion: Our protocol was similarly suitable for low-flux iHD, high-flux iHD, and oHDF, with only minor adaptations. Clotting, relevant calcium changes, metabolic or other complications were not observed. Our protocol could serve as a template for a commercial RCA solution in iHD.

Automated summary

The study compared the effectiveness of using RCA under different iHD modes and found that the protocol was similarly suitable for low-flux iHD, high-flux iHD, and oHDF with only minor adaptations. No clotting or relevant complications were observed, suggesting that the protocol could serve as a template for a commercial RCA solution in iHD.