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Kidney Week

Abstract: SA-PO1027

Hemodialysis with a Citrate Containing Ca- and Mg-Free Dialysis Fluid: Exit Heparin?

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • De Jong, Gijs M.T., Albert Schweitzer Hospital, Dordrecht, Netherlands
  • Korte, Mario R., Albert Schweitzer Hospital, Dordrecht, Netherlands
  • Vermeer, Henricus Jan, Albert Schweitzer Hospital, Dordrecht, Netherlands
  • van Rosmalen, Joost, Erasmus MC, Rotterdam, Netherlands
  • Meulen, Jan Van der, Albert Schweitzer Hospital, Dordrecht, Netherlands

Hemodialysis (HD) with heparin increases mortality of bleeding. Regional anticoagulation with citrate (C) HD (infusion of C before dialyzer, Ca-, Mg-free dialysis fluid and Ca/Mg substitution after dialyzer) may decrease this risk, but is laborious. This study describes the effect of adding C to the Ca-, Mg-free dialysis fluid.


In 12 HD patients on anticoagulants (6 vit. K antagonist; 6 acetylsalicylic acid), 2 HD sessions with dalteparin (D) and 2 with C were performed. During D dialysis fluid contained Ca 1.5 and Mg 0.5 mmol/l. During C, a Ca-, Mg-free, 0.8 mmol/l C containing dialysis fluid was used. Ca 540/ Mg 240 mmol/l substitution was 35 ml/h. Before, during and after HD, urea, ionized Ca (iCa), Mg were tested and clotting tests (APTT, NATEM full blood CT (ROTEM Delta, Tem-innovations Munich) were done. Clotting phenomena in venous airtrap and dialyzer were graded by visual inspection (grade 0-2 respectively 0-3). Data were analyzed using linear mixed models to account for repeated measurements.


No HD was stopped prematurely. During C, clotting tests remained unaltered (APTT 31 vs 32 vs 32 sec; NATEM CT: 1079 vs 1052 vs 1048 sec). At D, clotting tests became significantly abnormal (APTT: 32 vs 42 vs 35 sec; NATEM CT: 1132 vs 2892 vs 1913 sec; p<0.001). Small clots in the venous airtrap were seen in 3/46 sessions (2C and 1D). There were significant more clotting phenomena in the dialyzer after C vs D (mean (95% CI) score 1.8 (1.6-2.1) vs 1.0 (0.7-1.2), p<0.001). spKt/V was slightly but significantly lower after C than after D (mean (95% CI) score 1.53 (1.37-1.69) vs 1.61 (1.45-1.76), p=0.045). iCa was stable during C but increased during D (C: 1.18 vs 1.15 vs 1.19; D: 1.16 vs 1.24 vs 1.25 mmol/l). In C, iCa after the dialyzer showed adequate anticoagulation (iCa 0.18 mmol/l). Mg increased slightly in C and decreased in D with a significant difference (p<0.001) during and after HD (C: 1.04 vs 1.06 vs 1.09; D: 1.00 vs 0.86 vs 0.84 mmol/l).


HD with a 0.8 mmol/l citrate, calcium- and magnesium-free dialysis fluid was slightly but clinically irrelevant inferior to HD with dalteparin without changing clotting tests in patients. Thus, citrate HD probably may prevent the increased risk of bleeding in patients already on maintenance anticoagulants.


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