A prospective, observational, feasibility study was carried out on four patients with
end-stage renal failure undergoing
bicarbonate hemodialysis to study the feasibility of an on-line
hemodiafiltration technique using a
citrate dialysate with pre-dilutional infusion of
citrate as a technique for regional
citrate anticoagulation. All patients had
contraindication to systemic
heparin anticoagulation. The dialysis technique consisted of an on-line
hemodiafiltration with a
citrate dialysate without
calcium using a Fresenius 4008S dialysis machine and Fresenius
Polysulfone F60 dialyzers. The infusion
solution was procured directly from the
dialysate and was infused into the
arterial line. To avoid the risk of
hypocalcemia,
calcium gluconate was infused to the venous return line. The study was carried out in two stages. During the first stage, the
citrate infusion rate was 80 mL/min and the
calcium infusion rate was 9 mmol/h. At the second stage, the rates were 100 mL/min and 11 mmol/h, respectively. The primary endpoint of this study was the incidence of
thrombosis in the extracorporeal blood circuit and/or the dialyzer. A total of 78 sessions were conducted. All the sessions were well tolerated clinically and there were no major incidents in any of the four patients. At the first stage of the study, there were five incidences of small clots in the venous blood chamber, an incidence of extracorporeal blood circuit
thrombosis of 12.5%. At the second stage of the study, no cases of extracorporeal blood circuit or dialyzer
thrombosis were noted.
Hemodiafiltration with on-line
citrate dialysate infusion to the
arterial line is safe and allows an effective regional anticoagulation of the extracorporeal blood circuit without the need for systemic anticoagulation.