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Aniort J, Richard F, Thouy F, Le Guen L, Philipponnet C, Garrouste C, Heng AE, Dupuis C, Adda M, Julie D, Elodie L, Chupin L, Bouvier D, Souweine B, Cindea N. Deciphering simplified regional anticoagulation with citrate in intermittent hemodialysis: a clinical and computational study. Sci Rep 2024; 14:19778. [PMID: 39187537 PMCID: PMC11347690 DOI: 10.1038/s41598-024-70708-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 08/20/2024] [Indexed: 08/28/2024] Open
Abstract
Regional citrate anticoagulation use in intermittent hemodialysis is limited by the increased risk of metabolic complications due to faster solute exchanges than with continuous renal replacement therapies. Several simplifications have been proposed. The objective of this study was to validate a mathematical model of hemodialysis anticoagulated with citrate that was then used to evaluate different prescription scenarios on anticoagulant effectiveness (free calcium concentration in dialysis filter) and calcium balance. A study was conducted in hemodialyzed patients with a citrate infusion into the arterial line and a 1.25 mmol/L calcium dialysate. Calcium and citrate concentrations were measured upstream and downstream of the citrate infusion site and in the venous line. The values measured in the venous lines were compared with those predicted by the model using Bland and Altman diagrams. The model was then used with 22 patients to make simulations. The model can predict the concentration of free calcium, bound to citrate or albumin, accurately. Irrespective of the prescription scenario a decrease in free calcium below 0.4 mmol/L was obtained only in a fraction of the dialysis filter. A zero or slightly negative calcium balance was observed, and should be taken into account in case of prolonged use.
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Affiliation(s)
- Julien Aniort
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
- INRAE UMR 1019, Human Nutrition Unit, Clermont Auvergne University, Clermont-Ferrand, France.
| | - Felix Richard
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - François Thouy
- Intensive Care Unit, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Louis Le Guen
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Carole Philipponnet
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Cyril Garrouste
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Anne Elisabeth Heng
- Nephrology, Dialysis and Transplantation Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, CHU G. Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- INRAE UMR 1019, Human Nutrition Unit, Clermont Auvergne University, Clermont-Ferrand, France
| | - Claire Dupuis
- Intensive Care Unit, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Mireille Adda
- Clinical Research Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Durif Julie
- Biochemistry Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | | | - Laurent Chupin
- Blaise Pascal Mathematics Laboratory, UMR 6620, Clermont Auvergne University, CNRS, Cezeaux Campus, Clermont-Ferrand, France
| | - Damien Bouvier
- Biochemistry Department, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Bertrand Souweine
- Intensive Care Unit, CHU Clermont-Ferrand, Gabriel Montpied Hospital, Clermont-Ferrand, France
| | - Nicolae Cindea
- Blaise Pascal Mathematics Laboratory, UMR 6620, Clermont Auvergne University, CNRS, Cezeaux Campus, Clermont-Ferrand, France
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Lefevre F, Vial R, Grellier S, Bujon S, Bouchouareb D, Brunet P, Scarfoglière V, Robert T. Toward acid- and heparin-free dialysis: the regional anticoagulation approach. Clin Kidney J 2024; 17:sfae201. [PMID: 39104871 PMCID: PMC11299105 DOI: 10.1093/ckj/sfae201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Indexed: 08/07/2024] Open
Abstract
Background In chronic intermittent hemodialysis, heparin is the standard anticoagulant as is the use of acid-containing dialysate. Regional anticoagulation (RA) with a calcium-free, citrate-containing dialysate has been developed. We compared RA using a calcium-free, citrate-free dialysate, routinely used in our center, versus systemic heparinization. Methods In a retrospective, observational, single-center, crossover study, we examined 15 patients undergoing chronic hemodialysis who were at high risk of bleeding and temporarily unable to use heparin. These patients received temporary treatment with RA involving calcium-free and citrate-free dialysate. We compared the dialysis session success rates during two distinct periods: standard heparinization and RA procedure with a calcium-free and citrate-free dialysate. Results In our study of 15 patients on chronic hemodialysis which compared 30 RA sessions versus 28 heparin-based anticoagulation session, we observed a 100% success rate with a median session duration of 240 min in both RA and heparin groups. No early extracorporeal circulation (ECC) loss was reported. However, we noted significant differences in the post-dialysis ECC thrombosis scores, with higher Global Thrombosis Index (GTI) and higher membrane coagulation scores in the RA group (P < .007 and P < .02, respectively). No hypocalcaemia or hypercalcemia symptoms occurred. Median post-filter ionized calcium levels were 0.32 (0.29-0.39) mmol/L at 30 min and median patient ionized calcium levels was 1.19 (1.135-1.28) mmol/L at 60 min. No significant difference in per-dialysis arterial blood pressure was observed between groups. Conclusion Our study evaluated the RA approach using a calcium-free, citrate-free acetate dialysate in a chronic hemodialysis center and found it effective. Although an acid-free dialysate was not used in this study, our findings suggest it could be the next frontier in the evolution of advanced dialysis techniques.
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Affiliation(s)
- Flora Lefevre
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Romain Vial
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Sophie Grellier
- Centre of Nephrology and Hemodialysis, Hôpital Sainte Musse, Toulon, France
| | - Solène Bujon
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Dammar Bouchouareb
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Philippe Brunet
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | | | - Thomas Robert
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
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Petitclerc T, Béné B. Can regional anticoagulation with calcium-free dialysate be extended to maintenance hemodialysis? Artif Organs 2024; 48:704-712. [PMID: 38716639 DOI: 10.1111/aor.14764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Regional anticoagulation in hemodialysis avoids the use of heparin, which is responsible for both hemorrhagic and non-hemorrhagic complications. Typically, blood is decalcified by injecting citrate into the arterial line of the extracorporeal circuit. Calcium-free dialysate improves anticoagulation efficacy but requires injection of a calcium-containing solution into the venous line and strict monitoring of blood calcium levels. Recent improvements have made regional anticoagulation with calcium-free dialysate safer and easier. OBSERVATIONS (1) Adjusting the calcium injection rate to ionic dialysance avoids the risk of dyscalcemia, thus making unnecessary the monitoring of blood calcium levels. This adjustment could be carried out automatically by the hemodialysis monitor. (2) As calcium-free dialysate reduces the amount of citrate required, this can be supplied by dialysate obtained from currently available concentrates containing citric acid. This avoids the need for citrate injection and the risk of citrate overload. (3) Calcium-free dialysate no longer needs the dialysate acidification required for avoiding calcium carbonate precipitation in bicarbonate-containing dialysate. CONCLUSIONS Regional anticoagulation with calcium-free dialysate enables an acid- and heparin-free procedure that is more biocompatible and environmentally friendly than conventional bicarbonate hemodialysis. The availability of specific acid-free concentrates and adapted hemodialysis monitors is required to extend this procedure to maintenance hemodialysis.
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Corbu A, Terrec F, Malvezzi P, Jouzier A, Jouve T, Rostaing L, Naciri Bennani H. Calcium-Free Dialysate Hemodialysis: A Simplified Approach. J Pers Med 2024; 14:660. [PMID: 38929882 PMCID: PMC11204440 DOI: 10.3390/jpm14060660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Intermittent hemodialysis (HD) in high-bleeding-risk patients presents a challenge as circuit anticoagulation using heparin is contraindicated in such cases. Recently, the use of calcium-free citrate-containing dialysate with calcium supplementation emerged as a viable alternative to heparin-circuit anticoagulation. This is a retrospective, monocentric study to evaluate dialysis efficacy using calcium-free citrate-containing dialysate with calcium reinjection into the venous line in hemodialysis patients at risk of bleeding. A total of 53 patients were analyzed: 52 had a temporary contraindication to systemic anticoagulation (active bleeding or surgical intervention), and 1 chronic HD patient had prolonged bleeding time due to inoperable arteriovenous fistula stenosis. Only 7 out of 79 dialysis sessions performed were prematurely terminated (vascular access dysfunction). The median dialysis time was 240 min (range: 150-300). The chronic dialysis patient had 108 sessions with no premature termination. Frequent monitoring of ionized calcium was performed throughout the dialysis sessions: levels remained stable at T0 and T + 60 min (1.08 ± 0.08 mmol/L) and slightly increased at the end of the dialysis session (1.19 ± 0.13 mmol/L), remaining within normal limits. Target postfilter ionized calcium <0.4 mmol/L was achieved in all sessions (0.31 ± 0.07 mmol/L). There were no cases of symptomatic hypo-/hypercalcemia and no need for calcium infusion rate adjustment throughout the sessions. Hemodialysis with calcium-free citrate-containing dialysate and calcium reinjection into the venous line is efficient and safe in HD patients with contraindications to systemic anticoagulation.
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Affiliation(s)
- Alexandra Corbu
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Florian Terrec
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Paolo Malvezzi
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Arnaud Jouzier
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
| | - Thomas Jouve
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Lionel Rostaing
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
- Univ. Grenoble Alpes Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences, 38000 Grenoble, France
| | - Hamza Naciri Bennani
- Nephrology, Haemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, 38043 Grenoble, France; (A.C.); (F.T.); (P.M.); (A.J.); (T.J.); (H.N.B.)
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5
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Tang X, Chen D, Zhang L, Fu P, Chen Y, Xiao Z, Xiao X, Peng W, Cheng L, Zhang Y, Li H, Li K, Gou B, Wu X, Yu Q, Jian L, Zhu Z, Wen Y, Liu C, Xue H, Zhang H, He X, Yan B, Zhong L, Huang B, Mao M. Application of regional citrate anticoagulation in patients at high risk of bleeding during intermittent hemodialysis: a prospective multicenter randomized controlled trial. J Zhejiang Univ Sci B 2022; 23:931-942. [PMID: 36379612 PMCID: PMC9676090 DOI: 10.1631/jzus.b2200082] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/19/2022] [Indexed: 02/19/2024]
Abstract
OBJECTIVES Safe and effective anticoagulation is essential for hemodialysis patients who are at high risk of bleeding. The purpose of this trial is to evaluate the effectiveness and safety of two-stage regional citrate anticoagulation (RCA) combined with sequential anticoagulation and standard calcium-containing dialysate in intermittent hemodialysis (IHD) treatment. METHODS Patients at high risk of bleeding who underwent IHD from September 2019 to May 2021 were prospectively enrolled in 13 blood purification centers of nephrology departments, and were randomly divided into RCA group and saline flushing group. In the RCA group, 0.04 g/mL sodium citrate was infused from the start of the dialysis line during blood draining and at the venous expansion chamber. The sodium citrate was stopped after 3 h of dialysis, which was changed to sequential dialysis without anticoagulant. The hazard ratios for coagulation were according to baseline. RESULTS A total of 159 patients and 208 sessions were enrolled, including RCA group (80 patients, 110 sessions) and saline flushing group (79 patients, 98 sessions). The incidence of severe coagulation events of extracorporeal circulation in the RCA group was significantly lower than that in the saline flushing group (3.64% vs. 20.41%, P<0.001). The survival time of the filter pipeline in the RCA group was significantly longer than that in the saline flushing group ((238.34±9.33) min vs. (221.73±34.10) min, P<0.001). The urea clearance index (Kt/V) in the RCA group was similar to that in the saline flushing group with no statistically significant difference (1.12±0.34 vs. 1.08±0.34, P=0.41). CONCLUSIONS Compared with saline flushing, the two-stage RCA combined with a sequential anticoagulation strategy significantly reduced extracorporeal circulation clotting events and prolonged the dialysis time without serious adverse events.
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Affiliation(s)
- Xiaoyan Tang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
- Department of Nephrology, People's Hospital of Jianyang City, Chengdu 641400, China
| | - Dezheng Chen
- Department of Nephrology, People's Hospital of Jianyang City, Chengdu 641400, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China.
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yanxia Chen
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Zhou Xiao
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Weisheng Peng
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Li Cheng
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Yanmin Zhang
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Hongbo Li
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Kehui Li
- Department of Blood Purification, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Bizhen Gou
- Department of Nephrology, Guiyang First People's Hospital, Guiyang 550002, China
| | - Xin Wu
- Department of Nephrology, Guiyang First People's Hospital, Guiyang 550002, China
| | - Qian Yu
- Department of Nephrology, Guiyang First People's Hospital, Guiyang 550002, China
| | - Lijun Jian
- Department of Nephrology, West China Hospital Sichuan University Jintang Hospital, Jintang 610400, China
| | - Zaizhi Zhu
- Department of Nephrology, Meishan People's Hospital, Meishan 620020, China
| | - Yu Wen
- Department of Nephrology, Ziyang People's Hospital, Ziyang 641300, China
| | - Cheng Liu
- Department of Nephrology, Ziyang People's Hospital, Ziyang 641300, China
| | - Hen Xue
- Department of Nephrology, Ya'an People's Hospital, Ya'an 625000, China
| | - Hongyu Zhang
- Department of Nephrology, Ya'an People's Hospital, Ya'an 625000, China
| | - Xin He
- Department of Nephrology, Chengdu Kangfu Kidney Disease Hospital, Chengdu 610047, China
| | - Bin Yan
- Department of Nephrology, the First People's Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, China
| | - Liping Zhong
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Bin Huang
- Department of Nephrology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Mingying Mao
- Department of Nephrology, People's Hospital of Jianyang City, Chengdu 641400, China
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Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting. Nephrourol Mon 2022. [DOI: 10.5812/numonthly-124164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is contraindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sustained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyzers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication.
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Medrano C, Cointault O, Lavayssiere L, Nogier MB, Colliou E, Setbon N, Kamar N, Faguer S. Heparin-free regional anticoagulation of haemodialysis filters with calcium-free dialysate: is citrate mandatory? Clin Kidney J 2021; 14:2534-2538. [PMID: 34950464 PMCID: PMC8690133 DOI: 10.1093/ckj/sfab087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background There is an unmet need to develop safe and successful heparin-free regional anticoagulation modalities in haemodialysed patients at risk of bleeding. Whether the addition of citrate as a prefilter injection or in the dialysate itself is required to reach anticoagulation objectives when calcium-free dialysate is used as regional anticoagulation remains unclear. Methods In this monocentric retrospective study, we report our experience of 908 dialysis sessions performed with a calcium-free citrate-containing dialysate and calcium reinjection according to the ionic dialysance, without additional heparin. Results Premature termination for filter clotting occurred in 20 sessions (2.2%) and duration of session was >4.5 h in 135 (15%; maximum duration 6 h). In addition, we could investigate the citrate, calcium and acid–basis status during haemodialysis sessions performed with (citrate group, n = 20 sessions) or without (citrate-free group, n = 19 sessions) citrate in the dialysate. In 20 sessions performed in patients with underlying liver disorders and using calcium-free citrate-containing dialysate, patients’ ionized calcium (iCa) and serum citrate levels were stable and remained within the normal range, respectively. Post-filter iCa was below 0.4 mmol/L in 19/20 sessions and citrate was 0.304 mmol/L (range: 0.011; 0.548). In 19 sessions that used calcium and citrate-free dialysate, post-filter iCa was 0.41 mmol/L (0.34; 0.5) and all sessions extended to 4 h or beyond. Conclusions Regional anticoagulation of haemodialysis with a calcium-free dialysate and calcium reinjection according to the ionic dialysance is safe. Adding citrate to the dialysate is not mandatory to prevent dialysis circuit clotting in most patients.
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Affiliation(s)
- Chloé Medrano
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurence Lavayssiere
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Marie-Béatrice Nogier
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Eloïse Colliou
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nicolas Setbon
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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8
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Respiratory Dialysis With Low Bicarbonate Dialysate in Critically Ill Patients: Is Acetate-Free Biofiltration the Answer? Crit Care Med 2021; 48:e1158. [PMID: 33038164 DOI: 10.1097/ccm.0000000000004523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Gubensek J, Persic V. Regional citrate anticoagulation for intermittent hemodialysis in the intensive care: what is the optimal setup? Ann Intensive Care 2021; 11:67. [PMID: 33939033 PMCID: PMC8093329 DOI: 10.1186/s13613-021-00858-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/23/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jakob Gubensek
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia. .,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia.
| | - Vanja Persic
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
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10
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Leroy C, Lautrette A. Response to the letter to the Editor "Regional citrate anticoagulation for intermittent hemodialysis in the intensive care. What is the optimal set-up?" by Gubensek et al. Ann Intensive Care 2021; 11:68. [PMID: 33939037 PMCID: PMC8093332 DOI: 10.1186/s13613-021-00859-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Christophe Leroy
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France.,Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France. .,LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France. .,Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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11
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Scarfoglière V, Bobot M, Guilhem C, Bouchouareb D, Brunet P, Robert T. Regional anticoagulation with calcium-free dialysate containing citrate in chronic haemodialysis patients. Nephrol Dial Transplant 2021; 36:745-746. [PMID: 33326039 DOI: 10.1093/ndt/gfaa365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Violaine Scarfoglière
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Mickaël Bobot
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Aix-Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Cavaille Guilhem
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Dammar Bouchouareb
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France
| | - Philippe Brunet
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,Aix-Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Thomas Robert
- Centre of Nephrology and Renal Transplantation, Hôpital de la Conception, CHU de Marseille, Marseille, France.,MMG, Bioinformatics & Genetics, UMR_S910, Aix-Marseille Université, Marseille, France
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12
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Locke A, Bushey MA, LaCroix C, Deardoff P, Onuigbo MAC. Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis. Mayo Clin Proc Innov Qual Outcomes 2021; 5:219-224. [PMID: 33718796 PMCID: PMC7930779 DOI: 10.1016/j.mayocpiqo.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion. He needed emergent therapeutic pericardiocentesis. Warfarin was promptly discontinued. He was discharged home with heparin-free HHD. Prior heparin anticoagulation for HHD was an initial bolus of 4000 units of heparin. He continued to clot his extracorporeal system with resultant very high venous pressures and compromised HHD. Heparin anticoagulation was still contraindicated. Flushes with 250-500 mL normal saline, delivered in aliquots every 15-30 minutes, failed to prevent the frequent clotting. The first author, our HD Senior Technician, had astutely observed that the horizontally placed hemodialysis filter exhibited early “clot” formation at the 12-o’clock position, despite the saline flushes. Through trial and error, he discovered that rotating the horizontally placed hemodialysis filter along its long axis, 60 degrees clockwise for 15 minutes, return to the neutral position for 15 minutes, rotating the filter another 60 degrees counterclockwise for 15 minutes, with this repeated cycle of rotations “did the trick.” It promptly and consistently resolved the clotting problem. The lines stopped clotting, and he has not needed saline flushes for smooth heparin-free HHD for more than 7 months. To our knowledge, this is the first such report. Further study is justified. We have hypothesized a mechanism and have named this the “Locke-Onuigbo Maneuver.”
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Affiliation(s)
- Adam Locke
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Margaret A. Bushey
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Cynthia LaCroix
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Patience Deardoff
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Macaulay Amechi Chukwukadibia Onuigbo
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
- The Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT
- College of Business, University of Wisconsin MBA Consortium, Eau Claire, WI
- Correspondence: Address to Macaulay Amechi Chukwukadibia Onuigbo, MD, MBA, Division of Nephrology, Department of Medicine, The Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT. UHC Campus, 1 South Prospect Street, Burlington, VT 05401. @MacO936298480
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13
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Petitclerc T, Ridel C. Routine online assessment of dialysis dose: Ionic dialysance or UV-absorbance monitoring? Semin Dial 2021; 34:116-122. [PMID: 33529406 DOI: 10.1111/sdi.12949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/01/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
For three-weekly hemodialysis, a single-pool Kt/V target of at least 1.4 together with a minimal dialysis dose Kt at 45 L for men and 40 L for women per each session is currently recommended. Fully automatic online calculation of Kt and Kt/V from conductivity or UV-absorbance measurements in the dialysate is standardly implemented on some hemodialysis monitors and makes it possible to estimate the dialysis dose without the need for blood or dialysate samples. Monitoring the UV-absorbance of the spent dialysate is the most direct method for estimating Kt/V as it does not require an estimate of V. Calculation of ionic dialysance from conductivity measurements is the most direct method for estimating Kt and BSA-scaled dialysis dose. Both ionic dialysance monitoring and UV-absorbance monitoring may help detect a change in urea clearance occurring during the session, but this change must be interpreted differently depending on the monitoring being considered. An abrupt decrease in urea clearance results in a decrease in ionic dialysance but, paradoxically, a sudden increase in estimated urea clearance provided by dialysate UV-absorbance monitoring. Healthcare teams who monitor both ionic dialysance and UV-absorbance in their hemodialysis units must be clearly informed of this difficulty.
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14
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Leroy C, Pereira B, Soum E, Bachelier C, Coupez E, Calvet L, Bachoumas K, Dupuis C, Souweine B, Lautrette A. Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study. Ann Intensive Care 2021; 11:13. [PMID: 33481169 PMCID: PMC7822996 DOI: 10.1186/s13613-021-00803-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Regional citrate anticoagulation (RCA) is the gold standard of anticoagulation for continuous renal replacement therapy but is rarely used for intermittent hemodialysis (IHD) in ICU. Few studies assessed the safety and efficacy of RCA during IHD in ICU; however, no data are available comparing RCA to heparin anticoagulation, which are commonly used for IHD. The aim of this study was to assess the efficacy and safety of RCA compared to heparin anticoagulation during IHD. METHODS This retrospective single-center cohort study included consecutive ICU patients treated with either heparin anticoagulation (unfractionated or low-molecular-weight heparin) or RCA for IHD from July to September in 2015 and 2017. RCA was performed with citrate infusion according to blood flow and calcium infusion by diffusive influx from dialysate. Using a propensity score analysis, as the primary endpoint we assessed whether RCA improved efficacy, quantified with Kt/V from the ionic dialysance, compared to heparin anticoagulation. The secondary endpoint was safety. Exploratory analyses were performed on the changes in efficacy and safety between the implementation period (2015) and at long term (2017). RESULTS In total, 208 IHD sessions were performed in 56 patients and were compared (124 RCA and 84 heparin coagulation). There was no difference in Kt/V between RCA and heparin (0.95 ± 0.38 vs. 0.89 ± 0.32; p = 0.98). A higher number of circuit clotting (12.9% vs. 2.4%; p = 0.02) and premature interruption resulting from acute high transmembrane pressure (21% vs. 7%; p = 0.02) occurred in the RCA sessions compared to the heparin sessions. In the propensity score-matching analysis, RCA was associated with an increased risk of circuit clotting (absolute differences = 0.10, 95% CI [0.03-0.18]; p = 0.008). There was no difference in efficacy and safety between the two time periods (2015 and 2017). CONCLUSION RCA with calcium infusion by diffusive influx from dialysate for IHD was easy to implement with stable long-term efficacy and safety but did not improve efficacy and could be associated with an increased risk of circuit clotting compared to heparin anticoagulation in non-selected ICU patients. Randomized trials to determine the best anticoagulation for IHD in ICU patients should be conducted in a variety of settings.
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Affiliation(s)
- Christophe Leroy
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- Intensive Care Unit, Regional Hospital Center, Puy en Velay, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Edouard Soum
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Bachelier
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Elisabeth Coupez
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Laure Calvet
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Konstantinos Bachoumas
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France.
- LMGE (Laboratoire Micro-Organismes: Génome et Environnement), UMR CNRS 6023, Université Clermont Auvergne, Clermont-Ferrand, France.
- Intensive Care Medicine, Gabriel Montpied Teaching Hospital, Intensive Care Unit, Centre Jean Perrin, 54 rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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15
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Vigneron C, Jamme M, Schurder J, Joseph A, Rondeau E, Lefèvre G, Ridel C, Rafat C. Efficacy and tolerance of sustained low-efficiency dialysis with calcium-free citrate-containing dialysate anticoagulation. Clin Kidney J 2020; 14:1025-1026. [PMID: 33777385 PMCID: PMC7986335 DOI: 10.1093/ckj/sfaa128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/08/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Clara Vigneron
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Matthieu Jamme
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Juliet Schurder
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Adrien Joseph
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Guillaume Lefèvre
- Laboratoire de Biochimie, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Ridel
- Centre d'hémodialyse et d'aphérèse, AURA Paris Plaisance, Paris, France
| | - Cédric Rafat
- Service des Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique - Hôpitaux de Paris, Paris, France
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Sethi SK, Mittal A, Nair N, Bagga A, Iyenger A, Ali U, Sinha R, Agarwal I, de Sousa Tavares M, Abeyagunawardena A, Hanif M, Shreshtha D, Moorani K, Asim S, Kher V, Alhasan K, Mourani C, Al Riyami M, Bunchman TE, McCulloch M, Raina R. Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children. Hemodial Int 2020; 24:237-251. [PMID: 32072767 DOI: 10.1111/hdi.12821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/06/2020] [Accepted: 01/12/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Recently, prolonged intermittent renal replacement therapies (PIRRT) have emerged as cost-effective alternatives to conventional CRRT and their use in the pediatric population has started to become more prominent. However, there is a lack of consensus guidelines on the use of PIRRT in pediatric patients in an intensive care setting. METHODS A literature search was performed on PubMed/Medline, Embase, and Google Scholar in conjunction with medical librarians from both India and the Cleveland Clinic hospital system to find relevant articles. The Pediatric Continuous Renal Replacement Therapy workgroup analyzed all articles for relevancy, proposed recommendations, and graded each recommendation for their strength of evidence. RESULTS Of the 60 studies eligible for review, the workgroup considered data from 37 studies to formulate guidelines for the use of PIRRT in children. The guidelines focused on the definition, indications, machines, and prescription of PIRRT. CONCLUSION Although the literature on the use of PIRRT in children is limited, the current studies give credence to their benefits and these expert recommendations are a valuable first step in the continued study of PIRRT in the pediatric population.
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Affiliation(s)
| | | | - Nikhil Nair
- Department of Chemistry Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Arpana Iyenger
- Pediatric Nephrology, St John's Medical College, Bangalore, India
| | - Uma Ali
- Pediatric Nephrology, Lilavati Hospital and Research Center and SRCC Children's Hospital, Mumbai, India
| | - Rajiv Sinha
- Pediatric Nephrology, Medanta, The Medicity, Gurgaon, India.,Pediatric Nephrology, National Institute of Child Health, Kolkata, India
| | | | | | | | - Mohammed Hanif
- Pediatric Nephrology, Bangladesh Institute of Child health, Dhaka, Bangladesh
| | | | - Khemchand Moorani
- Pediatric Nephrology, National Institute of Child Health, Karachi, Pakistan
| | - Sadaf Asim
- Pediatric Nephrology, National Institute of Child Health, Karachi, Pakistan
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Khalid Alhasan
- Pediatric Nephrology, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Chebl Mourani
- Pediatrics, Hôtel-Dieu de France Hospital (HDF), Beirut, Lebanon
| | | | - Timothy E Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mignon McCulloch
- Pediatric Nephrology, University of Cape Town - Cape Town, Western Cape, South Africa
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio
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Krummel T, Cellot E, Thiery A, De Geyer G, Keller N, Hannedouche T. Hemodialysis without anticoagulation: Less clotting in conventional hemodialysis than in predilution hemodiafiltration. Hemodial Int 2019; 23:426-432. [PMID: 31380605 DOI: 10.1111/hdi.12774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/22/2019] [Accepted: 06/23/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Hemodialysis patients with contraindication to systemic anticoagulation require a heparin-free hemodialysis technique. Among several alternatives to heparin, predilution hemodiafiltration (HDF) is often used, albeit without any confirmation of its effectiveness. METHODS Patients hospitalized in a nephrology ICU and hemodialysed for stage 5 CKD or AKI and with contraindication to systemic anticoagulation were randomized to either standard HD with a polysulfone membrane, or to predilution HDF with the same membrane. Coagulation activation was evaluated clinically by the need for premature termination and by the measurement of D-dimers. FINDINGS Two hundred dialysis sessions were performed in 155 patients. Survival curves showed better circuit survival in HD (P = 0.046). In HD, 12% of sessions were interrupted for coagulation versus 23% in predilution HDF (P = 0.04). DISCUSSION Predilution HDF was associated with more premature clotting than conventional HD without improvement in dialysis duration or performance epuration indices. When aiming for a 4-hour duration session, conventional heparin-free hemodialysis can be safely proposed in most patients with high bleeding risk.
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Affiliation(s)
- Thierry Krummel
- Department of Nephrology and Dialysis, University Hospital of Strasbourg, Strasbourg, France
| | - Etienne Cellot
- Department of Nephrology, General Hospital of Annecy, Annecy, France
| | - Alicia Thiery
- Department of Public Health, Centre Paul Strauss, Strasbourg, France
| | - Géraldine De Geyer
- Department of Nephrology and Dialysis, University Hospital of Strasbourg, Strasbourg, France
| | - Nicolas Keller
- Department of Nephrology and Dialysis, University Hospital of Strasbourg, Strasbourg, France
| | - Thierry Hannedouche
- Department of Nephrology and Dialysis, University Hospital of Strasbourg, Strasbourg, France
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The authors reply. Crit Care Med 2019; 46:e177-e178. [PMID: 29337814 DOI: 10.1097/ccm.0000000000002858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Heparin-Free Regional Anticoagulation: There Are Significant Differences Between Citrate-Containing Dialysate and Regional Citrate Anticoagulation. Crit Care Med 2019; 46:e176-e177. [PMID: 29337813 DOI: 10.1097/ccm.0000000000002793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Fanelli V, Cantaluppi V, Alessandri F, Costamagna A, Cappello P, Brazzi L, Pugliese F, Biancone L, Terragni P, Ranieri VM. Extracorporeal CO2 Removal May Improve Renal Function of Patients with Acute Respiratory Distress Syndrome and Acute Kidney Injury: An Open-Label, Interventional Clinical Trial. Am J Respir Crit Care Med 2018; 198:687-690. [DOI: 10.1164/rccm.201712-2575le] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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