Uncorrected Proof Nephro-Urol Mon. 2022 August; 14(3):e124164. Published online 2022 June 22. doi: 10.5812/numonthly-124164. Research Article Utility of Citrate Dialysis in Patients with Contraindication for Heparin in a Limited-Resource Setting Rajaram Jagdale 1, 2, 3, * , Alan Almeida 1 , Jatin Kothari 1 , Rasika Sirsat 1 , Supriya Surwase 4 and Dixon Thomas 5 1 Department of Nephrology, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India 2 Department of Nephrology, Thumbay University Hospital, Ajman, United Arab Emirates 3 College of Medicine, Gulf Medical University, Ajman, UAE 4 Microbiology, Thumbay Hospital, Dubai, United Arab Emirates 5 College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates * Corresponding author: Nephrology Department, Thumbay University Hospital, Ajman, UAE. Tel: +971-568547247, Email: rajaramjagdale@gmail.com Received 2022 March 20; Accepted 2022 April 18. Abstract Background: Hemodialysis among critical care patients with acute kidney injury (AKI) is challenging, especially if heparin is con- traindicated. Objectives: This study assessed the utility of citrate dialysis for such patients in a limited-resource setting. Methods: In this prospective study, patients were divided into group A (heparin-free saline flush dialysis), group B (heparin-free citrate dialysis without flushing), and group C (heparin-free citrate dialysis with flushing). The subjects underwent completed sus- tained low-efficiency daily dialysis (blood flow = 150 mL/minute, dialysate = 300 mL/minute) or intermittent hemodialysis (blood flow = 250 mL/minute, dialysate flow = 500 mL/minute). Statistical tests using SPSS software (version 26) were used to determine safety and effectiveness differences. Results: Among 25 patients studied with multiple hemodialysis sessions, blood flow and dialysate flow were observed to be better in heparin-free citrate dialysis with flushing. There were further advantages of lesser dialyzer clotting and more reuse of dialyz- ers. Metabolic differences were insignificant. Heparin-free citrate dialysis with or without flushing was equally effective and safe, compared to heparin-free saline flush dialysis, in patients with or without liver impairment. Conclusions: Citrate dialysis is observed to be a safe and effective alternative to heparin-free saline flushing dialysis in intensive care unit patients with AKI. More such studies are required in limited-resource settings to utilize citrate dialysis in patients with heparin contraindication. Keywords: Citrate Dialysis, Heparin Contraindication, Bleeding, Acute Kidney Injury 1. Background Acute kidney injury (AKI) patients in the intensive care unit (ICU) are complex to manage (1). Despite advances in renal replacement therapy (RRT) and critical care in re- cent years, the mortality rate remained high (2, 3). The risk, injury, failure, loss of kidney function, and end-stage renal failure (RIFLE) criteria consist of three graded levels of injury (i.e., risk, injury, and failure) based upon either the magnitude of the rise in serum creatinine or fall in urine output and two outcome measures (i.e., loss of kid- ney function and end-stage kidney disease [ESKD]) (4). Heparin is the conventional anticoagulant used dur- ing hemodialysis. When there are contraindications for heparin use, namely perioperative period, active bleeding, deranged coagulation profile, or heparin-induced throm- bocytopenia, it is necessary to resort to heparin-free dial- ysis in AKI patients admitted to the ICU. Dialyzer clotting is common in patients undergoing heparin-free dialysis (5, 6). Citrate dialysis, where citric acid functions as an an- ticoagulant, is an alternative to heparin-free dialysis with advantages, such as less dialyzer clotting, more dialyzer reuse, and a better-delivered dose of dialysis. Citrate dialysate has been successfully used in regional citrate an- ticoagulation (RCA) and has been more effective than re- peated saline flushing of the extracorporeal circuit (7). Cit- rate accumulation/toxicity due to failure to metabolize cit- rate, especially in chronic liver disease patients, is a rare problem due to the low concentration of citrate used in the dialysate. Citrate dialysate has been used for sustained Copyright © 2022, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.