"Heparin Free Slow Low Efficiency Dialysis (SLED) Using Citrasate Dialysate (CD) is Safe and Effective"

Annie Tu, MS, ARNP, CNN
Suhail Ahmad, MD
University of Washington, Seatle, WA

Summary & Conclusions:

All patients during 2005 requiring CRRT at the UWMC received SLED.
Patients with contraindication to heparin used CD for heparin free SLED treatments.
Ninety percent of SLED treatments were successfully completed.
The dialysate flow to blood flow ratio was found to be lower for unsuccessful treatments compared to the successful treatments. It is possible that the citrate delivery rate is one variable affecting the clotting of dialyzers.
The CD for long treatments was well tolerated with no adverse events noted.
Even prolonged use of CD was not associated with accumulation of citrate as judged by the
ionized to total calcium ratio. No hypocalcemia, hypernatremia or increase in anion gap was noted.
A significant decline in magnesium and an
increase in bicarbonate were seen, and all values
remained in normal ranges.
Many patients had significantly compromised liver function and, even in these acutely ill
patients, the CD was well tolerated without any adverse events.
CD is a viable alternative to heparin in acutely ill patients requiring SLED.

Background:
Anticoagulation for continuous therapies (CRRT) is particularly challenging in patients with increased risk of bleeding. Systemic anticoagulation is unsafe, regional citrate increases the risk of citrate accumulation and its toxicity, hypocalcemia, alkalosis & hypernatremia.
Citrate containing dialysate (CD) has been safely and effectively
used for heparin free intermittent hemodialysis, however its use in CRRT has not been as well documented.

Patients & Methods:
During 2005, Forty-seven hemodynamically unstable ICU patients at the University of Washington Medical Center needed
CRRT but the use of heparin was unsafe:

HIT - 6 patients
Active bleeding - 41 patients

These patients underwent 117 heparin free SLED treatments using CD (Citrasate®, Advanced Renal Technologies, Bellevue, WA).

Underlying Conditions:

Advanced Liver Failure / liver transplant: 25
Stem Cell Transplant: 10
Solid organ transplants: 6
Others: 6

Comorbidities:

Multi-organ failures: 25
Sepsis:29

SLED:

Blood Flow Rate: 198 + 71 ml/min.
Dialysate Flow Rate: 287 +85 ml/min.
Dialyzers: Polyflux 6L, 8L & 10L - 85%
F– 5 dialyzers - 15%
Duration: 6 - 24 hours; average 9.6 + 4.3 hours

Completed Treatments:
Completion of treatment duration as ordered (> 6 hours) or clot free for > 12 hour duration.

Clotted Treatments:
Treatment stopped due to clots either before the completion of ordered duration or before 12 hours.