"Citrate-Containing Dialysate Is Well Tolerated During
Slow Extended Daily Dialysis In The ICU"
James R. Madison DO, MS(1), Margarita P Ilumin MSN, RN(2), Andrew I Chin MS(1)
1 Division of Nephrology, University of California Davis Medical Center, and
2 Renal Services Program, University of California Davis Center, Sacramento, CA, U.S.A.
Discussion:
- Citrate-bases dialysate appears safe, since we observed no adverse events during 6 hour SLEDD treatments
- Citrasate was more effective than Saline flushes alone, at completing anticoagulant-free SLEDD treatments in the ICU
- We observed significantly less clotting events in those on Citrasate + hourly saline flushes (16%), compared to those receiving Saline flushes every 30 or 60 minutes alone (30%)
- Despite the statistical significance, serum ionized calcium levels remained clinically stable during all SLEDD treatments
- Use of Citrasate required significantly less frequent flushing of dialysis circuits and thereby reduced nursing time
Based on our experiences, a randomized, prospective trial, to further study the benefits citrate-based dialysate is warranted
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Background:
- Slow Extended Daily Dialysis (SLEDD) is a well tolerated method of Continuous Renal Replacement in ICU patients
- There is a concern about the amount of anticoagulation used to maintain the dialysis circuit during extended treatments
- Citrate based dialysate (Citrasate) has been used to perform heparin-free, outpatient intermittent hemodialysis
- Citrasate was used to perform SLEDD in our ICU patients with clinical contraindication to the use of anticoagulation
- In this report, we review our experience with the safety and efficacy of Citrasate compared to those receiving Saline flushes alone during anticoagulant-free SLEDD in the ICU
Methods:
- UCDMC patients, receiving inpatient dialysis during 2005
- Patients were admitted to 1 of 7 Intensive Care Units
For inclusion patients must be > 18 years, and on SLEDD with clinical contraindication to the use of any form of anticoagulation - All patients received 200 cc saline flushes at least every hour
- Citrasate treated patients were compared to other SLEDD treated patients receiving Saline flushes alone 30 to 60 minutes
- Clotting was defined as: Early discontinuation of dialysis, greater than 30 minutes prior to prescribed time, because of circuit clotting in either the lines, chambers or dialyzer
- Data was abstracted by chart review and groups were compared using Chi-Square, T-test and ANOVA
Slow Extended Daily Dialysis (6-8 hour) Prescription
- Prescription: Qb=200 ml/min, Qd=400 ml/min, with either the typical acid profile: Na+140, K+4, Ca+2.5, or Citrasate 30
- Monitoring: Record any dialysis related adverse event, continuous cadiac monitoring, mean arterial pressure, and location of any chamber, circuit or dialyzer clotting were documented
- Observations: Pre- and Post- ionized CA++, goal and attained ultrafiltration, the need/use of vasopressors, and treatment completion or duration for every dose was recorded
Limitations:
- Retrospective observational, single center Review
- Small Cohort, non-randomized
- Experiences influenced by highly skilled Renal Services support
- Limited to available, documented data
Acknowledgements:
- The authors affirm there is no conflict of interest, we have no commercial relationship with any company selling citrate-based dialysate
- The authors wish to express their gratitude to the UCDMC Renal Services Department for their professionalism and dedication