Clinical observation of two-stage regional citrate anticoagulation in hemodialysis with high risk of bleeding

Objective To observe the safety and efficacy of two-stage regional citrate anticoagulation (RCA) in high-flux hemodialysis with calcium-containing dialysate in patients with high risk of bleeding.Methods The maintenance hemodialysis patients with high risk of bleeding, which met criteria for citrate anticoagulation were divided into two groups. 4% citrate anticoagulation solution was infused both prior to dialyser and at venous bubble in the group of TS-RCA, and 4% citrate anticoagulation solution was only infused prior to dialyser in the group of simplified RCA (S-RCA). Standard calcium-containing dialysate was used in the groups of TS-RCA and S-RCA, and not administered with calcium supplement in venous circuit. Clinical dialysis parameters and coagulation situations of dialyser and venous bubble were observed regularly during the treatment. The above parameters were compared between the two groups.Results A total of 300 high-flux hemodialysis sessions in 89 patients were included. 180 high-flux hemodialysis sessions were treated by two-stage RCA, the effective blood volume was 150 mL/min, dialysate volume was 300 mL/min, and mean volume of 4% trisodium citrate was (225.6±14.2) mL/h prior to dialyzer and (18.5±3.3) mL/h at venous bubbler. 120 high-flux hemodialysis sessions were treated by simplified RCA, the effective blood volume was 200 mL/min, dialysate volume was 300 mL/min, and mean volume of 4% trisodium citrate was (275.6±25.4) mL/h prior to dialyzer. There was no significant difference in the effective rate of anticoagulation prior to the dialyzer between S-RCA and TS-RCA groups (97.3% vs. 97.7%, χ²=0.0244, P=0.876). The effective rate of anticoagulation at the venous bubble in the TS-RCA group was significantly higher than in the S-RCA group (96.8% vs. 69.6%, χ²=33.77, P=0.000).Conclusions Two-stage RCA is a safe and effective anticoagulation option for hemodialysis patients with high risk of bleeding. Two-stage RCA is superior to simplified RCA in the effective rate of anticoagulation, and is worth referring for dialysis clinical practice.