Safety and efficacy of regional citrate anticoagulation during 8-hour sustained low-efficiency dialysis

Background and objectives: Patients who may benefit from sustained low-efficiency dialysis therapy are often at risk for bleeding. A safe and simple "regional" anticoagulation strategy would be beneficial. The modification of existing regional citrate anticoagulation protocols to typically performed 8-h sustained low-efficiency dialysis is necessary. Design, setting, participants, & measurements: Sustained low-efficiency dialysis was performed at blood and dialysate rates of 250 and 300 ml/min, respectively. The circuit was anticoagulated with 4% sodium citrate (citrate 136, sodium 408 mmol/L) and reversed with CaCl2. Every 2 h, electrolytes, ionized circuit, and patient calcium were monitored during the first two versions. The second version differed by an increased infusion of CaCl2 and lower infusion of citrate, both by 10%. The third version measured only laboratory values before and after sustained low-efficiency dialysis. Results: There were 41 treatments in the first iteration, 42 in the second, and 34 in the final iteration. All versions were titrated to maintain patient ionized calcium of 4.0 to 4.8 mg/dl (1.0 to 1.2 mmol/L) and the circuit ionized calcium between 0.8 and 1.6 mg/dl (0.2 and 0.4 mmol/L. The final protocol infusion was 31 mmol/h citrate and 41 mmol/h elemental calcium, which kept circuit and patient ionized calcium at targets. No unexpected metabolic complications occurred. Conclusions: Compared with continuous renal replacement therapy, one must increase the calcium infusion because of the more efficient removal of the calcium citrate complex. Safe and effective regional citrate anticoagulation can be performed in 8-h sustained low-efficiency dialysis without metabolic complications with laboratory surveillance only before and after sustained low-efficiency dialysis treatment; however, certain safeguards are mandatory.