**6. References**


loading is another topic that has been receiving more and more attention in recent years and is another domain of solute kinetic modeling that should ultimately be integrated into citrate dialysis modeling, particularly given the additional sodium load administered with

The use of dialysate-side citrate anticoagulation (i.e., the use of a citrate- and calciumcontaining dialysate without arterial citrate infusion or venous calcium substitution) has sparked interest recently for its alleged heparin-sparing potential and its safety and ease of use [27-29]. At unchanged heparin doses, using citrate-containing dialysate (instead of

Citrate anticoagulation holds great promises for improving the outcomes of hemodialysis patients. Ultimately, kinetic modeling will be essential for taking this therapy to the next level (i.e., a high degree of individualization and increased safety through accurate prediction of electrolyte and acid-base kinetics) and to facilitate its widespread use in

[1] Suranyi M, Chow JS: Review: anticoagulation for haemodialysis. Nephrology (Carlton)

[2] Arepally GM, Ortel TL: Clinical practice. Heparin-induced thrombocytopenia. N Engl J

[3] Kishimoto TK, Viswanathan K, Ganguly T, Elankumaran S, Smith S, Pelzer K, Lansing

[4] Blossom DB, Kallen AJ, Patel PR, Elward A, Robinson L, Gao G, Langer R, Perkins KM,

[5] Morita Y, Johnson RW, Dorn RE, Hall DS: Regional anticoagulation during hemodialysis

[6] Buturovic-Ponikvar J, Cerne S, Gubensek J, Ponikvar R: Regional citrate anticoagulation

[7] Pedersen KO: Binding of calcium to serum albumin. I. Stoichiometry and intrinsic

[8] Pedersen KO: Binding of calcium to serum albumin. II. Effect of pH via competitive

[9] Pedersen KO: Binding of calcium to serum albumin. IV. Effect of temperature and

contact system. N Engl J Med 2008;358(23):2457-2467.

using citrate. Am J Med Sci 1961;242:32-43.

trial. Int J Artif Organs 2008;31(5):418-424.

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JC, Sriranganathan N, Zhao G, Galcheva-Gargova Z, Al-Hakim A, Bailey GS, Fraser B, Roy S, Rogers-Cotrone T, Buhse L, Whary M, Fox J, Nasr M, Dal Pan GJ, Shriver Z, Langer RS, Venkataraman G, Austen KF, Woodcock J, Sasisekharan R: Contaminated heparin associated with adverse clinical events and activation of the

Jaeger JL, Kurkjian KM, Jones M, Schillie SF, Shehab N, Ketterer D, Venkataraman G, Kishimoto TK, Shriver Z, McMahon AW, Austen KF, Kozlowski S, Srinivasan A, Turabelidze G, Gould CV, Arduino MJ, Sasisekharan R: Outbreak of adverse reactions associated with contaminated heparin. N Engl J Med 2008;359(25):2674-

for hemodialysis: calcium-free vs. calcium containing dialysate - a randomized

association constant at physiological pH, ionic strength, and temperature. Scand J

hydrogen and calcium ion binding to the imidazole groups of albumin. Scand J

thermodynamics of calcium-albumin interaction. Scand J Clin Lab Invest

bicarbonate dialysate acidified with acetate) appears to improve solute removal [30].

the use of regional citrate anticoagulation.

routine clinical practice.

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**6. References** 


**12** 

*New Jersey Medical School, United States of America* 

**Hemodialysis Principles and Controversies** 

The incidence rates of End-stage renal disease (ESRD) have increased steadily internationally since 1989. The United States has the highest incident rate of ESRD, followed by Japan; Japan has the highest prevalence per million population, with the United States second (1). Of the 490,000 patients with ESRD in the United States, more than 380,000 are

ESRD on HD disproportionately affects minority populations. Whites represent the majority of the HD population (59.8%), while African Americans (33.2%), Asians (3.6%), and Native Americans (1.6%) comprise the rest of the ESRD population. However, the incidence rate of ESRD among African Americans is 4-fold higher and Native Americans 2-fold higher than that for whites. ESRD is slightly more prevalent in men than in women (male-to-female

Chronic renal failure is associated with a very high morbidity and hospitalization rate, likely due to existing comorbid conditions, such as hypertension, coronary artery disease, and peripheral vascular disease. The first-year age-adjusted mortality rate of patients on dialysis is 9.4%, the two-year mortality rate is 32.3%, and the 5-year mortality rate is 60.8% (3). ESRD patients with diabetes have a first-year mortality rate of 23% (3). In patients with ESRD, cardiovascular disease is the primary cause of death, followed by sepsis and cerebrovascular disease. The dialysis population in the United States has a 10- to 20-fold higher risk of death due to cardiovascular complications than the general population after adjusting for age, race, and sex. The relative risk with respect to the general population is much higher in younger patients, with cardiovascular event rates in ESRD patients in their 20s equivalent to the event rates in the general population in their 80s (3). Increased understanding of the disease process, new insights into pathogenic mechanisms, and new therapeutic options are

emerging that may improve survival rates and quality of life for patients with ESRD.

Given the poor outcomes for patients on HD, every effort should be undertaken to preserve residual renal function, which is associated with improved survival (4). Early nephrology referrals, patient education, and consideration of transplant options may be helpful in decreasing the progression to ESRD. Preparation for dialysis therapy is critical for the

**1. Introduction** 

currently on hemodialysis (HD) (2).

**2. Morbidity/mortality** 

**3. The need for dialysis** 

ratio, 1.2:1) and more prevalent in older adults (3).

Parin Makadia, Payam Benson, Filberto Kelly and Joshua Kaplan

