responsible for the care of dialysis patients are well aware
of the complex relationship between treatment variables
and patient outcome. Much depends upon the interaction between
the patient's blood and the extracorporeal circuit, especially
within the hemodialyzer. Even with systemic heparin anticoagulation,
clotting within the dialyzer reduces delivered "dose" of
dialysis, increases blood loss, and limits dialyzer reuse.
Dialyzer clotting is further accelerated in cases where
heparin anticoagulation is contraindicated, for example,
in patients with antibodies to this agent. These complications
result in additional staff time required to treat the problems,
as well as higher costs for additional supplies (dialyzers,
blood lines, etc.).
Management of postsurgical
and trauma patients with increased risk of bleeding limits
the use of heparin, making the dialysis especially challenging.
The alternatives to heparin therapy in this group are limited
to periodic flushes of the circuit or to regional citrate
anticoagulation. Although widely used, line flushing is
relatively ineffective and increases fluid load to the patient.
The alternative, regional citrate anticoagulation, is difficult
to deliver properly and expensive to set up and monitor.
Both methods involve significant additional effort on the
part of the staff.
Furthermore, in patients
receiving uncomplicated, "routine dialysis," the goal is
to optimize treatment by increasing the dose of dialysis
within the constraints of available time and cost. Advanced
Renal Technologies (ART) has developed a new dialysate formulation
that addresses these problems and brings treatment to a
more effective level. Containing citric acid as the acidifying
agent, it is the first major change in dialysate formulation
in over two decades, breaking away from traditional formulations
that contain acetic acid. It is cleared for use by the FDA,
and is already on the market and in use in clinics.
Citrate dialysate is
not to be confused with regional citrate anticoagulation,
in which high concentrations of citric acid are infused
into the arterial blood line to bind calcium, and a corresponding
infusion of calcium is delivered into the venous line or
through the dialyzer to counteract hypocalcemia. Citrate
dialysate has been used successfully in place of in-hospital
regional citrate anticoagulation, and it is more effective
than repeated saline flushing of the extracorporeal circuit.
Citric acid content
of both Citrasate® and DRYalysate®
is only 2.4 mEq/L in the final diluted concentration within
the dialyzer, well below the 7-15 mEq/L threshold of true
anticoagulation (ref. 2). Calcium levels in the patient
remain within the normal range when citrate dialysate is
used, and no supplemental calcium replacement measures are
Making the conversion
from conventional dialysate to citrate dialysate is effortless.
The conversion is "transparent" for both staff and dialysis
- No adjustment in the dialysis
system is required; simply substitute citrate concentrate
for the A concentrate normally used.
- Additional staff training is
- There is no need to perform
additional patient monitoring beyond ordinary measures.
No blood tests are needed.
traditional acetic acid-containing dialysates, citrate dialysate
has the following documented benefits:
- Citrate dialysate increases
the delivered "dose" of dialysis for the patient, including
improved Kt/V and URR and increased predialysis serum
bicarbonate levels. (ref.3)
- Citrate dialysate can raise
average dialyzer reuse by more than 60% on all patients,
and by over 100% on patients considered "problem clotters."
Consequently, for the facility seeking to cut operating
costs, ART's citrate dialysate is an effective solution.
- Citrate dialysate can be used
for heparin-free dialysis of patients with antibodies
to heparin. (ref. 1, 5)
- Where heparin anticoagulation
is contraindicated, citrate dialysate can be used for
dialysis of patients with acute renal failure who are
at risk of bleeding. In most cases, citrate dialysate
reduces or eliminates the need to flush the extracorporeal
circuit with saline. (ref. 5)
Frequently Asked Questions
citrate dialysate the same as regional citrate anticoagulation?
A: No. Performing citrate dialysis is no different
operationally than doing regular dialysis. There is no regional
infusion of citric acid employed. "It's all in the dialysate."
Q: Is it necessary to do continuous calcium infusions
into the venous blood line, as is done for regional citrate
anticoagulation, in order to avoid problems associated with
A: No. Calcium binding by dialysate citrate is so
small that no significant alteration in calcium occurs during
dialysis (ref. 3). The citrate content of the dialysate
is only 2.4 mEq/L.
Q: How does citrate dialysate provide the noted patient
A: As you know, citric acid is an anticoagulant.
Its presence in the dialysate in 2.4 mEq/L concentration
provides some anticoagulation effect in the dialyzer and
venous blood line that is quickly neutralized upon reentry
into the systemic circulation.
Q: Is it necessary to check clotting times when citrate
dialysate is used?
Q: Is there reason to be concerned about bleeding
risk, hypocalcemia, or hypomagnesemia when treating patients
with citrate dialysate?
A: No. Because the concentration of citrate in the
dialysate is well below the level needed to produce anticoagulation
of the patient's blood, there is no risk of bleeding or
low blood mineral levels from citrate use.
Q: Are Citrasate® and DRYalysate®
cleared for clinical use by the FDA?
Q: How do I adapt my present dialysis system to allow
the use of Citrasate® or DRYalysate®
A: You don't need to adapt your system to the new
dialysate formulation. No changes are necessary. Citrasate®
concentrate is available in all the standard concentrations
and formulations. You simply pour it into your standard
A concentrate container and attach it to your dialysis system
as you always do. If you prefer to mix A concentrate from
powder, DRYalysate® is available for this purpose,
and it can be mixed in your facility to make concentrate.
Q: What steps are necessary before citrate dialysis
can be started?
A: Both Citrasate® and DRYalysate®
may be used in existing dialysis systems without altering
them. Also, there is no additional patient or system monitoring
needed beyond that normally employed in treatment with standard
dialysate formulations. Consequently, no staff training
is necessary for the conversion to citrate dialysate.
Q: Can citrate dialysate be "spiked" with potassium
A: Yes, it can be spiked just as you do with traditional
Q: How is citrate dialysate supplied?
A: It is available in two different forms, each with
a final citric acid concentration of 2.4 mEq/L: Citrasate®
is a liquid A concentrate that comes in 1 gallon jugs and
barrels, in concentrations of 35X, 36.83X, and 45X. The
jugs are packed four to the case. DRYalysate®
is the dry equivalent of Citrasate® . For those
facilities that prefer to mix A concentrate from dry ingredients,
DRYalysate® is the choice. Because dry citric
acid is already included, no separate liquid acid needs
to be added which makes it possible to ship and store a
completely dry formulation until it is needed. DRYalysate®
comes in boxes that make 50 liters of A concentrate in any
of the three concentrations noted.
Q: How do I obtain Citrasate® and DRYalysate®
A: Advanced Renal Technologies is the sole source
for these two products.
- Pinnick RV, Wiegmann TB, Diederich
DA. Regional citrate anticoagulation for hemodialysis
in the patient at high risk for bleeding. N Engl J
Med. 308(5):258-261, 1983.
- Ahmad S, Callan R, Cole JJ,
Blagg CR. Dialysate made from dry chemicals using citric
acid increases dialysis dose. Am J Kidney Dis.
- Tu A, Ahmad S. Heparin-free
hemodialysis with citrate-containing dialysate in intensive
care patients. Dial Transplant. 29(10):620-626,
- Tu A, Ahmad S. Heparin-free
dialysis using citrate dialysate. Abstr. J Am Soc Nephrol.
- Ahmad S, Callan, R, Cole JJ,
Blagg CR. Effect of citrate-containing dialysate on dialyzer
reuse. Abstr. J Am Soc Nephrol. 11:A0919, 2000.
Phone: (425) 453-8777
Fax: (425) 451-9438
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