Citrate- vs. acetate-based dialysate in bicarbonate haemodialysis: consequences on haemodynamics, coagulation, acid-base status, and electrolytes

Luca Gabutti, Barbara Lucchini, Claudio Marone, Lorenzo Alberio, Michel Burnier, Luca Gabutti, Barbara Lucchini, Claudio Marone, Lorenzo Alberio, Michel Burnier

Abstract

Background: 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. 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.

Methods: In 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.

Results: Patients 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.

Conclusion: The 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 registration: ClinicalTrials.gov NCT00718289.

Figures

Figure 1
Figure 1
Study design. Schematic representation of the study design.
Figure 2
Figure 2
Evaluation of the fluctuations in haemodynamic parameters. Schematic representation of the method used to calculate the maximum increase and decrease of each measured parameter during the dialysis session.
Figure 3
Figure 3
Systolic blood pressure. Systolic blood pressure as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 4
Figure 4
Diastolic blood pressure. Diastolic blood pressure as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 5
Figure 5
Heart rate. Heart rate as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 6
Figure 6
Blood volume. Blood volume as a function of the haemodialysis time using respectively acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 7
Figure 7
Stroke volume. Stroke volume as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 8
Figure 8
Peripheral resistance. Peripheral resistance as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds), calcium uncorrected citrate (C) (black squares) and calcium supplemented citrate dialysate (C+) (black triangles).
Figure 9
Figure 9
Systolic blood pressure in hypertensive patients. Systolic blood pressure as a function of the haemodialysis time using, respectively, acetate (A) (empty diamonds) and calcium uncorrected citrate (C) (black squares) dialysate in the subgroup of patients with an intradialytic systolic blood pressure increase during dialysis of more than 15 mmHg and at least one value of more than 150 mmHg (n = 8).

References

    1. Ahmad S, Callan R, Cole JJ, Blagg CR. Dialysate made from dry chemicals using citric acid increases dialysis dose. Am J Kidney Dis. 2000;35:493–499. doi: 10.1016/S0272-6386(00)70203-4.
    1. Tu A, Ahmad S. Heparin-free hemodialysis with citrate-containing dialysate in intensive care patients. Neph Dial Transplant. 2000;29:620–626.
    1. Ahmad S, Callan R, Cole J, Blagg C. Increased dialyzer reuse with citrate dialysate. Hemodial Int. 2005;9:264–267. doi: 10.1111/j.1492-7535.2005.01140.x.
    1. Apsner R, Buchmayer H, Gruber D, Sunder-Plassmann G. Citrate for long-term hemodialysis: prospective study of 1,009 consecutive high-flux treatments in 59 patients. Am J Kidney Dis. 2005;45:557–564. doi: 10.1053/j.ajkd.2004.12.002.
    1. Pinnick RV, Wiegmann TB, Diederich DA. Regional citrate anticoagulation for hemodialysis in the patient at high risk for bleeding. N Engl J Med. 1983;308:258–61.
    1. Bauer E, Derfler K, Joukhdar C, Druml W. Citrate kinetics in patients long-term hemodialysis therapy. Am J Kidney Dis. 2005;46:903–907. doi: 10.1053/j.ajkd.2005.07.041.
    1. Gabutti L, Marone C, Colucci G, Duchini F, Schönholzer C. Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge. Intensive Care Med. 2002;28:1419–1425. doi: 10.1007/s00134-002-1443-y.
    1. Gabutti L, Colucci G, Martella A, Schönholzer C, Marone C. Does monitoring of pre-/post-dialyzer pressure difference improve efficiency in intermittent hemodialysis? Blood Purif. 2003;21:294–300. doi: 10.1159/000072548.
    1. Gabutti L, Ferrari N, Mombelli G, Keller F, Marone C. The favorable effect of regional citrate anticoagulation on interleukin-1beta release is dissociated from both coagulation and complement activation. J Nephrol. 2004;17:819–825.
    1. Stiekema JC. Heparin and its biocompatibility. Clin Nephrol. 1986;26:S3–8.
    1. Cheung AK, Faezi-Jenkin B, Leypoldt JK. Effect of thrombosis on complement activation and neutrophil degranulation during in vitro hemodialysis. J Am Soc Nephrol. 1994;5:110–115. doi: 10.1159/000106705.
    1. Böhler J, Schollmeyer P, Dressel B, Dobos G, Hörl W. Reduction of granulocyte activation during hemodialysis with regional citrate anticoagulation: dissociation of complement activation and neutropenia from neutrophil degranulation. J Am Soc Nephrol. 1996;7:234–241.
    1. Hofbauer R, Moser D, Frass M, Oberbauer R, Kaye AD, Wagner O, Kapiotis S, Druml W. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int. 1999;56:1578–1583. doi: 10.1046/j.1523-1755.1999.00671.x.
    1. Bos JC, Grooteman MP, Van Houte AJ, Schoorl M, Van Limbeek J, Nube MJ. Low polymorphonuclear cell degranulation during citrate anticoagulation: a comparison between citrate and heparin dialysis. Nephrol Dial Transplant. 1997;12:1387–1393. doi: 10.1093/ndt/12.7.1387.
    1. Dhondt A, Vanholder R, Tielemans C, Glorieux G, Waterloos MA, De Smet R, Lameire N. Effect of regional citrate anticoagulation on leukopenia, complement activation and expression of leukocyte surface molecules during hemodialysis with unmodified cellulose membranes. Nephron. 2000;85:334–342. doi: 10.1159/000045683.
    1. Bartels PC, Schoorl M, Wiering JG, Nube MJ. Activation of coagulation during treatment with hemodialysis. Scand J Clin Lab Invest. 2000;60:283–290. doi: 10.1080/003655100750046440.
    1. Wiegmann TB, McDougall ML, Diederich DA. Dialysis leukopenia, hypoxemia and anaphylatoxin formation: effect of membrane, bath and citrate anticoagulation. Am J Kidney Dis. 1988;11:418–424.
    1. Fischer KG. Essentials of anticoagulation in hemodialysis. Hemodial Int. 2007;11:178–189. doi: 10.1111/j.1542-4758.2007.00166.x.
    1. Kaye M, Vasilevsky M, Ketis M. The effect on blood pressure of an acute fall in ionized calcium during hemodialysis. A randomized study in two patients. Clin Nephrol. 1998;50:361–366.
    1. Sande FM Van der, Cheriex EC, Van Kuijk WHM, Leunissen KML. Effect of dialysate calcium concentrations on intradialytic blood pressure course in cardiac-compromised patients. Am J Kidney Dis. 1998;32:125–131. doi: 10.1053/ajkd.1998.v32.pm9669433.
    1. Leunissen KML, Berg BW Van den, van Hooff JP. Ionized calcium plays a pivotal role in controlling blood pressure during haemodialysis. Blood Purif. 1989;7:233–239. doi: 10.1159/000169600.
    1. Sherman RA, Bialy GB, Gazinski B, Bernholc AS, Eisinger RP. The effect of dialysate calcium levels on blood pressure during hemodialysis. Am J Kidney Dis. 1986;8:244–247.
    1. Maynard JC, Cruz C, Kleerekoper M, Levin NW. Blood pressure response to changes in serum ionized calcium during hemodialysis. Ann Intern Med. 1986;104:358–361.
    1. Gabutti L, Ross V, Duchini F, Mombelli G, Marone C. Does Bicarbonate transfer have relevant hemodynamic consequences in standard hemodialysis? Blood Purif. 2005;23:365–372. doi: 10.1159/000087193.
    1. Gabutti L, Ferrari N, Giudici G, Mombelli G, Marone C. Unexpected haemodynamic instability associated with standard bicarbonate haemodialysis. Nephrol Dial Transplant. 2003;18:2369–2376. doi: 10.1093/ndt/gfg383.
    1. Nossel HL, Yudelman I, Canfield RE, Butler VP, Spanondis K, Wilner GD, Qureshi GD. Measurement of fibrinopeptide A in human blood. J Clin Invest. 1974;54:43–53. doi: 10.1172/JCI107749.
    1. Papadoyannakis NJ, Stefanidis CJ, McGeown M. The effect of correction of metabolic acidosis on nitrogen and potassium balance of patients with chronic renal failure. Am J Clin Nutr. 1984;40:623–627.

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