Abstract
BackgroundA concentrate for bicarbonate haemodialysis acidified with citrate instead of acetate has been marketed in recent years. The small amount of citrate used (one-fifth of the concentration adopted in regional anticoagulation) protects against intradialyser clotting while minimally affecting the calcium concentration. The aim of this study was to compare the impact of citrate- and acetate-based dialysates on systemic haemodynamics, coagulation, acid-base status, calcium balance and dialysis efficiency.MethodsIn 25 patients who underwent a total of 375 dialysis sessions, an acetate dialysate (A) was compared with a citrate dialysate with (C+) or without (C) calcium supplementation (0.25 mmol/L) in a randomised single-blind cross-over study. Systemic haemodynamics were evaluated using pulse-wave analysis. Coagulation, acid-base status, calcium balance and dialysis efficiency were assessed using standard biochemical markers.ResultsPatients receiving the citrate dialysate had significantly lower systolic blood pressure (BP) (-4.3 mmHg, p < 0.01) and peripheral resistances (PR) (-51 dyne.sec.cm-5, p < 0.001) while stroke volume was not increased. In hypertensive patients there was a substantial reduction in BP (-7.8 mmHg, p < 0.01). With the C+ dialysate the BP gap was less pronounced but the reduction in PR was even greater (-226 dyne.sec.cm-5, p < 0.001). Analyses of the fluctuations in PR and of subjective tolerance suggested improved haemodynamic stability with the citrate dialysate. Furthermore, an increase in pre-dialysis bicarbonate and a decrease in pre-dialysis BUN, post-dialysis phosphate and ionised calcium were noted. Systemic coagulation activation was not influenced by citrate.ConclusionThe positive impact on dialysis efficiency, acid-base status and haemodynamics, as well as the subjective tolerance, together indicate that citrate dialysate can significantly contribute to improving haemodialysis in selected patients.Trial registrationClinicalTrials.gov NCT00718289
Highlights
A concentrate for bicarbonate haemodialysis acidified with citrate instead of acetate has been marketed in recent years
(page number not for citation purposes) http://www.biomedcentral.com/1471-2369/10/7 as a function of haemodialysis time are depicted in Figures 3, 4, 5, 6, 7, 8. This observation was confirmed in an analysis of the maximum fluctuations in systolic blood pressure during dialysis, in which the citrate dialysate produced, respectively, a larger decrease and a less pronounced increase (+6.4 and -4.9 mmHg; p < 0.01 and p < 0.05 respectively)
The opposite was observed regarding peripheral resistances with a less pronounced decrease (-489 dyne.sec.cm-5; p < 0.001) and a similar maximum increase that was confirmed with citrate dialysate supplemented with 0.25 mmol calcium/L
Summary
A concentrate for bicarbonate haemodialysis acidified with citrate instead of acetate has been marketed in recent years. The small amount of citrate used (one-fifth of the concentration adopted in regional anticoagulation) protects against intradialyser clotting while minimally affecting the calcium concentration. In contrast to traditional regional citrate anticoagulation, the small amount of citrate used in the acid concentrate (0.8 mmol/L; only about one-fifth of the concentration necessary to achieve anticoagulation [1,4,5]) affects the calcium concentration and the locally enhanced coagulation activation in a limited way, resulting in approximately 10% reduction in post-dialysis ionized calcium and in no measurable systemic anticoagulation [1]. Despite the rapid clearance of citrate, the local consequences of removing calcium from the blood clotting cascade have measurable positive effects on the dialyser life-span in the "reuse" modality and on dialysis quality, as quantified by urea Kt/V [1,3]. Considering the importance of limiting the biocompatibility-related coagulation activation taking place in the extracorporeal circuit [9,10,11,12,13,14,15,16,17], the availability of a simple way to inhibit it without affecting systemic coagulation and bleeding risk [18] is very promising
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