Abstract
BackgroundRegional citrate anticoagulation (RCA) during hemodialysis interferes with calcium homeostasis. Optimal ionized calcium (iCa) target range during RCA and consequent calcium balance are unknown.MethodsIn a randomized controlled trial (ACTRN12613001029785) 30 chronic hemodialysis patients were assigned to normal (1.1–1.2 mmol/) or low (0.95–1.05 mmol/l) iCa target range during a single hemodialysis with RCA. The primary outcome was calcium mass balance during the procedure, using a partial spent dialysate collection method; magnesium mass balance was also measured. Intact parathormone (iPTH), total calcium (tCa) and magnesium were measured before and after procedures.ResultsMean iCa during procedures was significantly different in the two groups (1.12±0.06 in normal and 1.06±0.07 mmol/l in low iCa group, p <0.001), resulting in different tCa (2.18±0.22 vs. 1.95±0.17, p = 0.003) after the procedure. Mean delivered calcium during the procedure was 58.3±4.8 mmol in the normal and 51.5±8.2 mmol in the low iCa group (p = 0.010), which resulted in a significantly higher mean positive calcium mass balance of 14.6±8.3 mmol (584±333 mg) per procedure in normal as compared to 7.2±8.5 mmol (290±341 mg) in low iCa group (p = 0.024). Linear mixed effects model showed a significant interaction effect of time and iCa target range group on iPTH, i.e. a significant increase in iPTH in the low as compared to normal iCa target group (p = 0.008). Magnesium mass balance was mildly negative and comparable in both groups.ConclusionsLow iCa target range resulted in a significantly less positive calcium mass balance, but in a significant increase in iPTH. To achieve a more neutral calcium balance, we recommend allowing a mild hypocalcemia during hemodialysis with RCA, especially when it is used for prolonged periods.
Highlights
In recent years, regional citrate anticoagulation (RCA) has become the preferred method of anticoagulation in continuous renal replacement therapy [1, 2], while in chronic hemodialysis it is the preferred method in patients with increased bleeding risk
To achieve a more neutral calcium balance, we recommend allowing a mild hypocalcemia during hemodialysis with RCA, especially when it is used for prolonged periods
A knowledge of the calcium mass balance during RCA is especially important when RCA is used for prolonged periods of time, or even permanently, in selected dialysis patients with persistent bleeding risk [8], or if RCA were to become the preferred mode of anticoagulation in chronic dialysis as well, as has already been the case in continuous methods
Summary
Regional citrate anticoagulation (RCA) has become the preferred method of anticoagulation in continuous renal replacement therapy [1, 2], while in chronic hemodialysis it is the preferred method in patients with increased bleeding risk. The main reason for the increased popularity of RCA is the excellent anticoagulation achieved, which is entirely regional, i.e., limited to the extracorporeal circuit, and enables better circuit run-times in continuous renal replacement therapy [2]. There are already some reports of small groups of chronic dialysis patients treated with long-term RCA hemodialysis due to persistently increased bleeding risk or other contraindications for heparin [7, 8]. Optimal ionized calcium (iCa) target range during RCA and consequent calcium balance are unknown
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