Heparin-Free Prolonged Intermittent Hemodialysis Using Calcium-Free Citrate Dialysate in Critically Ill Patients

Crit Care Med. 2017 Nov;45(11):1887-1892. doi: 10.1097/CCM.0000000000002694.


Objectives: Critically ill patients who have a high risk of bleeding but require prolonged intermittent dialysis need a heparin-free easy-to-use alternative type of anticoagulation within the dialysis circuit. We assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance.

Design: Prospective cohort study.

Setting: Critical care units.

Patients: Critically ill patients who required renal replacement therapy.

Interventions: None.

Measurements and main results: A total of 101 dialysis sessions were performed in 35 patients (mechanical ventilation n = 78; norepinephrine n = 13). Median duration of dialysis was 294 minutes (interquartile range, 240-300), and median ultrafiltration volume was 2.3 L (1-2.8). Urea and β2-microglobulin reduction rates were 64.5% ± 0.4% and 48% ± 0.13%, respectively. Postfilter ionized calcium was 0.35 ± 0.17 and 0.38 ± 0.14 mmol/L at 1 and 3 hours, respectively, within the extracorporeal circuit. A major clotting event that led to premature termination of the session occurred in only three of 101 sessions. In these three cases, major catheter dysfunction occurred before clotting within the circuit. Prefilter ionized calcium remained within narrow ranges (before/after change +0.07 ± 0.006 mmol/L), and total-to-ionized calcium ratio, a surrogate marker for citratemia, was unchanged.

Conclusions: Dialysis anticoagulation with calcium-free citrate-containing dialysate and calcium reinjection according to ionic dialysance is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation. It allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. Furthermore, sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe acute kidney disease.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Calcium Chloride / administration & dosage
  • Citric Acid / administration & dosage*
  • Critical Illness / therapy*
  • Dialysis Solutions / administration & dosage*
  • Dialysis Solutions / chemistry*
  • Female
  • Heparin
  • Humans
  • Intensive Care Units
  • Male
  • Middle Aged
  • Renal Dialysis / methods*


  • Dialysis Solutions
  • Citric Acid
  • Heparin
  • Calcium Chloride