Citrate versus heparin anticoagulation in chronic haernodialysis patients

Anticoagulation with citrate at a rate of 0.68 mM/min in combinationwith a calcium and magnesium-free dialysate and i.v. supplementationof calcium and magnesium at rates of 0.18 mM/min and 0.08 mM/minrespectively, was compared with lowdose heparin. The heparindose was a loading dose of 2500 IU and a sustaining infusionof 750–1250 IU/h; or a loading dose of 1250 IU and a sustaininginfusion of 500–750 IU–h until I h before the endof the dialysis if the patlent was taking concomitantly coumarinanticoagulation for a Goretex shunt. Six chronic haemodialysispatients changed from heparin to citrate anticoagulation becausethey reported bleeding between dialyses. Heparin, after 2 hdialysis, induced a significant 10% prolongation of each patient'swholeblood activated clotting tlme (WBACT) as compared to thepredialysis value: while the WBACT at the dialyser outlet wasless than 3% prolonged as compared to the patient's WBACT. However,after 2 h cltratc the patient's WBACT was not prolonged butthe WBACT at the dialyser outlet was 20–100°A longer,indicating a better anticoagulation of the extracorporeal systemwithout systemic effects. With heparin the shunt pressure time(SPT). i.e. the time needed to stop bleeding from the puncturesites of the Goretex shunts. was 12 of 28 tlrnes 20 niln ormore Citrate reduced these episodes by 75%. Thus citrate should be considered for chronic haemodialysispatients who are at risk of bleeding because of the concomitantuse of anticoagulants. Other patients who could benefit fromcltrate are those with premorbid vascular abnormalities suchas intestinal arterlovenous malforniations. diabetic retinopathymalignant hypertension or adult polycystic kidney disease. Claimsthat cltrate gave improved biocompatibility. 1.e. less leukopeniaor thrombocytopenia. were not confirmed. lndications that citratecaused better dialysis efficiency were found. but should beconfirmed In a greater number of patients.