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Regional Anticoagulation with Sodium Citrate in Pediatric Patients on Intermittent Hemodialysis Therapy with Bleeding Risks

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Abstract:

Heparin-free anticoagulation in hemodialysis (HD) is advocated for patients with clotting abnormalities and risk of bleeding. Objective: 

First publication on regional citrate anticoagulation (RCA) in children. RCA is free from systemic effects, guarantees excellent dialyzer life, but requires careful monitoring. Methods: 

We report on 3 patients treated by intermittent RCA HD (4 h each, high-flux dialyzer F40, Fresenius): (1) 17-year-old boy (renal transplant failure, access via cubital Cimino fistula) after hypertensive intra-cerebral hemorrhage (2 sessions); (2) 13-year-old girl (hemolytic uremic syndrome, access via jugular vein Shaldon catheter) after abdominal surgery and bleeding (8 sessions); and (3) 7-year-old boy (hyperoxaluria, access via PermCath® jugular vein catheter) after renal transplant biopsy (3 sessions). Sodium citrate 30% was infused into the extra corporeal circuit (blood flow 150 mL/min) before dialyzer (initial flow 30 mL/min) and calcium gluconate 10% for antidote into venous line near of catheter or fistula (initial flow 40 mL/min). Post-dialyzer extracorporeal serum Ca++ (aim < 0.3 mmol/L) and pre-dialyzer intra-corporeal Ca++ (aim > 0.9) were measured for every 30 min. Serum Na+, K+, base excess (BE), blood flow, blood pressure, heart rate, and blood out-flow and in-flow pressure were also monitored. Results: 

For adequate RCA (mean extracorporeal serum Ca++ 0.24 ± 0.04 mmol/L), a mean citrate flow of 36.1 ± 5.9 mL/h and a mean calcium substitution rate of 40.8 ± 3.4 mL/h were needed. Intra-corporeal Ca++ was kept at 1.10 ± 0.07 mmol/L. Extracorporeal activated clotting time (ACT) was 194 ± 41 and intra-corporeal ACT 90 ± 12 sec. Serum Na+, K+, and BE during HD were 138 ± 2, 3.5 ± 0.3, and −0.6 ± 1.1 mmol/L, respectively. Mean arterial blood pressures of patients 1–3 were 117 ± 5, 103 ± 5, and 102 ± 6 mmHg. All patients were stable and without any bleeding during HD. The only adverse event was 1 episode of hypocalcemia (Ca++ < 0.6 mmol/L) cured by stopping dialysis. Conclusions: 

Local anticoagulation with sodium citrate during intermittent HD can be applied safely in children and adolescents.

Document Type: Research Article

DOI: http://dx.doi.org/10.1111/j.1492-7535.2004.0085ca.x

Affiliations: Department of Pediatric Nephrology, University Children's Hospital, Essen, Germany.

Publication date: January 1, 2004

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