Regional citrate anticoagulation (RCA) .......

Submitted by Mr CS Soong

Regional citrate anticoagulation is safe in intermittent
high-flux haemodialysis treatment of children and
adolescents with an increased risk of bleeding

Web-Flash: 28 April 2010

Nephrology Dialysis Transplantation - NDT Advance Access
published online on April 26, 2010

Martin Kreuzer 1, Klaus-Eugen Bonzel 2, Rainer Büscher 2,
Gisela Offner 1, Jochen H.H. Ehrich 1 and Lars Pape 1

1 Department of Paediatric Nephrology, Hannover Medical
School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
2 Department of Paediatrics II, Paediatric Nephrology,
University of Duisburg Essen, Hufelandstrasse 55, 45122,
Essen, Germany


Abstract

Background. Regional citrate anticoagulation (RCA) is
strongly recommended for adults with an increased risk of
bleeding complications. The objective of this
retrospective analysis was to evaluate an RCA protocol
concerning feasibility and safety in intermittent
high-flux haemodialysis (iHD) treatment in children and
adolescents.

Methods. Eighteen children and adolescents aged 5–17
years (median 15 years) underwent 74 iHD treatment
sessions with RCA. Twelve of 18 patients presented with
overt local or diffuse haemorrhage before beginning the
HD sessions, and six had an increased risk of
haemorrhagic complications. Forty children on acute
haemodialysis with general heparin anticoagulation,
matched for bleeding risk, age and body surface area,
served as a control group. Citrate 3% solution was begun
with 3.3% blood flow rate, and calcium gluconate 10%
substitution was started with 0.4% of blood flow rate.
Citrate flow was adapted to achieve a post-filter ionized
calcium of 0.30 mmol/L; calcium substitution was adapted
to maintain the patients’ serum calcium levels within the
physiological range. Calcium-free dialysis fluid was
used. The blood flow rate ranged from 3 to 5 mL per
minute and kilogram body weight.

Results. Regional anticoagulation was successfully
achieved within the extracorporeal blood circuit, while
the coagulation of all 18 patients remained within
physiological parameters. No adverse effects of RCA were
observed. In all 18 children, neither new haemorrhage nor
worsening of the bleeding situation occurred, and in
10/12 patients, bleeding stopped during dialysis with
RCA. In contrast, one-third of the control group
developed new haemorrhagic complications or presented
with worsening of pre-existing bleeding during
haemodialysis (P = 0.006).

Conclusion. RCA is feasible, safe and effective in
paediatric intermittent haemodialysis treatment.