" Increased Kt/V and Decreased Beta-2 With Citrate Dialysate"

"HIGH CITRATE DIALYSATE IS SAFE AND PERMITS HEPARIN FREE CHRONIC HEMODIALYSIS (HD)"

Mary Dittrich, MD1, Robin Callan, LLM2, Suhail Ahmad, MD3.
1Boise Kidney & Hypertension Institute, Meridian, ID,
2Advanced Renal Technologies, Bellevue, WA,
3University of Washington, Seattle, Washington, USA

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Background:

Citrate dialysate (CD) is a bicarbonate dialysate acidified using 2.4 mEq/L of citrate.
CD has been shown to increase delivered dose (Kt/Vurea) of dialysis.
CD is often used for heparin free acute dialyses.
The above suggest that CD prevents clotting of dialyzers and dialysis system.
However, clotting of the system is still encountered in some treatments.
It is proposed that using a higher citrate concentration (4.0 mEq/L, “CD 4.0”) would be
more effective in permitting heparin reduction.
The study evaluated:
- The safety of CD 4.0, by clinical observations and monitoring ionized Ca, total Ca and Mg.
- The efficacy of CD 4.0 by:
  - The dose of dialysis (Kt/Vurea and URR).
  - The ability to successfully reduce heparin.

Patients & Methods:

10 chronic HD patients dialyzing 3 times a week consented to participate. The study involved four experimental dialyses:
1. Regular dialysate and heparin (5167 u).
2. CD 4.0 and regular heparin dose.
3. CD 4.0 dialysate and 1/2 heparin dose (2894 u).
4. CD 4.0 dialysate and heparin free ( 0 u).
Hourly measurements of ionized (iCa), total Ca (tCa) , urea, Mg, and other electrolytes were taken at the participants bedside.
The dialysis circuits and dialyzers were observed for any clotting as well as the line pressures were also continuously monitored


Hourly Total Calcium, Magnesium and Ionized Calcium		DoseHeparin Dose per Dialysis NOTE: The average “full” heparin used in the first citrate dialysate treatment is reduced because two patients were treated heparin free for medical reasons.


URR by Hour with Regular Dialysate and Citrate Dialysate		Dialysis Dose (Kt/Vurea)

Results:

All dialyses with CD 4.0 were without any complications; patients tolerated each treatment well.
The dialyzers and tubing sets did not show excessive clotting.
Two of 10 heparin free treatments were terminated early due to line pressure alarms - both in the final 30 minutes of the treatment.
No patient had any symptoms of hypocalcemia or hypomagnesemia.
The dialysis dose did not decrease from baseline either during heparin reduced or heparin free dialysis.

Summary & Conclusions:

Higher citrate dialysate (CD 4.0) was well tolerated without any complications.
CD 4.0 did not significantly reduce ionized or total Ca and was found to be safe for chronic dialysis.
CD 4.0 permitted successful completion of dialysis treatments with a 50% reduction in heparin.
The dose of dialysis with CD 4.0 increased significantly even with 50% reduction in heparin.
80% of the heparin free dialyses were successfully completed with CD 4.0 use.
The two partially completed treatments both had higher Kt/V results than their baseline.
This first study in chronic HD patients shows that higher citrate dialysate (CD 4.0) is safe to use, is effective in permitting heparin reduction and, was associated with a higher dose of dialysis.