Alternatives to heparin anticoagulation in intermittent hemodialysis and their possible application in intensive care patients

Abstract

Intermittent hemodialysis usually requires transient systemic anticoagulation with heparin, fractionated or not, in order to avoid clotting of the extracorporeal circuit. In patients at high risk of hemorrhage, various methods can be used. Two methods give excellent results, with a reported very low frequency of clotting of the extracorporeal circuit, but have the disadvantage of a significant technical implementation : (i) regional anticoagulation with citrate (which also potentially exposes to citrate accumulation); (ii) the use of citrate-enriched dialysate without calcium and without magnesium, with reinfusion of calcium and magnesium according to ionic dialysance. Other processes have the advantage of being very simple to implement : (i) short daily intermittent dialysis sessions (2 hours) ; (ii) longer dialysis sessions (4 hours), using an dialysis membrane coated with heparin and/or a commercial dialysate containing both citrate and calcium ; otherwise one may systematically change the extracorporeal circuit and the membrane after the second hour. Although widely used, the technique of iterative flushes or continuous predilution of the extracorporeal circuit with isotonic saline gives poor results but can be used if no other above-cited technique is applicable.