Regional citrate anticoagulation for intermittent predilution online hemofiltration.

There is no consensus on the optimal renal replacement treatment in intensive care units. Among intermittent dialysis methods, hemofiltration (HF) is preferred by some because of better hemodynamic stability and cytokine removal. We report our experience with regional citrate anticoagulation for intermittent predilution online HF. Forty-one patients (age 69 +/- 10 years, 73% male) with acute renal failure and an increased bleeding risk in intensive care units were included in this retrospective analysis. Citrate anticoagulation was performed with 4% citrate (starting at 400 mL/h) and 1 mol/L calcium chloride (starting at 7 mL/h). Calcium-containing (1.25 mmol/L) infusate, prepared online, was used. Anticoagulation was assessed visually after HF in a subgroup of 36 procedures using a score of 5 (no clotting) to 1 (total occlusion). The duration of the 94 HF sessions performed was 4 h 50 min +/- 47 min, and the infusate volume reached was 77 +/- 9 L. During HF, ionized calcium increased (1.01 +/- 0.14 to 1.13 +/- 0.09 mmol/L, P < 0.001), and the increases in sodium (141 +/- 5 to 143 +/- 3 mmol/L, P < 0.001) and bicarbonate (23 +/- 6 to 25 +/- 4 mmol/L, P < 0.01) were significant, but small. There were two cases of metabolic alkalosis (pH > 7.5) not requiring any intervention. None of the circuits clotted. The mean anticoagulation assessment scores were 4.6 +/- 0.6 at the arterial bubble trap, 4.2 +/- 1.0 at the dialyzer, and 4.2 +/- 0.9 at the venous bubble trap. To conclude, regional citrate anticoagulation for predilution online hemofiltration with calcium-containing infusate provides a good anti-thrombotic effect and has rare metabolic side effects.