Original Paper
Nephron Clin Pract 2004;98:c35–c40
DOI: 10.1159/000079925
A Simple, Safe and Effective Citrate
Anticoagulation Protocol for the Genius®
Dialysis System in Acute Renal Failure
Stanislao Morgeraa Cornelia Schollea Christoph Melzerb Torsten Slowinskia
Lutz Liefelda Gerd Baumannb Harm Petersa Hans-H. Neumayera
Departments of a Nephrology and b Cardiology, Charité, Humboldt University of Berlin, Berlin, Germany
Key Words
Citrate anticoagulation · Genius® dialysis · Acute renal
failure · Acid base · Electrolytes
Abstract
Background: The Genius® dialysis system is a close loop
dialysis batch system increasingly used as an intermit-
tent hemodialysis device in intensive care units. The aim
of this study was to test the safety and feasibility of a
regional citrate anticoagulation protocol with respect to
acid-base and electrolyte disarrangements in critically ill
patients with acute renal failure. A standard heparin an-
ticoagulation protocol served as control. Methods and
Results: In a cross-over study design, 27 acute renal fail-
ure patients were allocated to a citrate- and heparin-an-
ticoagulated dialysis sessions (4–6 h). For citrate antico-
agulation, a 4% sodium-citrate solution was infused into
the arterial line of the extracorporeal circuit. A low cal-
cium dialysate (1 mmol/l) was used for all dialysis ses-
sions. Citrate dosing was adjusted according to the post-
filter ionized calcium concentration (targeted values
0.5–0.7 mmol/l). There was no routine calcium substitu-
tion. Heparin anticoagulation was started with a heparin-
loading dose followed by an individual, patient-adjusted
continuous heparin infusion. Electrolyte disarrange-
ments, namely hypernatremia, hypo- and hypercalcemia
© 2004 S. Karger AG, Basel
1660–2110/04/0981–0035$21.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/nec
Received: January 5, 2004
Accepted: May 5, 2004
did not occur in either group. Although the highest bi-
carbonate levels were achieved during citrate anticoagu-
lation (p = 0.021 versus heparin) the acid base values
remained equilibrated in both groups. Filter longevity
was excellent and the targeted dialysis time was achieved
in all but 1 patient. Citrate anticoagulation was well tol-
erated with respect to cardiovascular hemodynamics.
Conclusions: Citrate anticoagulation can be safely and
effectively performed during intermittent Genius® dialy-
sis. Calcium supplementation is not routinely required.
Copyright © 2004 S. Karger AG, Basel
Introduction
The Genius® dialysis system is a single pass batch sys-
tem originally developed by Tersteegen and Van Endert
[1] for the treatment of chronic renal failure patients. It
has now found its way into intensive care units as an al-
ternative to continuous renal replacement therapies. It
can be applied as an intermittent hemodialysis as well as
in a slow extended dialysis procedure [2]. The Genius®
dialysis system is mobile, simple to handle and highly
flexible with respect to the dialysate composition [3, 4].
Adequate anticoagulation is a precondition for every
effective hemodialysis therapy to prevent clotting in the
extracorporeal circuit. Heparin has been the most fre-
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library
Dr. med. Stanislao Morgera
Universitätsklinikum Charité, Humboldt Universität zu Berlin
Medizinische Klinik mit Schwerpunkt Nephrologie am CCM
Schumannstrasse 20–21, DE–10098 Berlin (Germany)
Downloaded by:
Tel. +49 30 450 514902, Fax +49 30 450 614137, E-Mail stanislao.morgera@charite.de
quently used anticoagulant but is associated with several
disadvantages such as life-threatening hemorrhagic com-
plications or the induction of heparin-induced thrombo-
cytopenia type II [5–7]. In recent years, the regional an-
ticoagulation with sodium-citrate has gained popularity,
especially in patients with increased bleeding risks or sus-
pected thrombocytopenia type II. By virtue of chelating,
ionized calcium citrate is a very efficient anticoagulant.
Anticoagulation is exclusively confined to the extracorpo-
real circulation. However, citrate anticoagulation has
some potential adverse effects such as metabolic alkalo-
sis, hypernatremia, hypo- and hypercalcemia.
This study presents a citrate anticoagulation protocol
for the Genius® dialysis system. In a cross-over design,
we compared a citrate anticoagulation protocol to that
using a standard heparin regime. We focused on the clin-
ical feasibility and the safety criteria, namely electrolytes,
acid-base values and cardiovascular hemodynamics.
Materials and Methods
Study Design
The study was approved by the Ethical Committee on Human
Research of the University Hospital Charité of Berlin and was in
accordance with the Declaration of Helsinki.
Twenty-seven patients with acute renal failure were enrolled
into the study after written consent was obtained from either the
patients or their relatives. Acute renal failure was based on one of
the following criteria: (1) fluid overload owing to inadequate urine
production despite administration of diuretic agents and mainte-
nance of adequate blood pressure; (2) a rise in serum creatinine
above 2.5 mg/dl (from normal baseline values) or a doubling of
the baseline creatinine value, and (3) serum potassium above
5.5 mmol/l due to oligoanuria.
In a cross-over design, patients were sequentially allocated to
the citrate anticoagulation protocol during the first study dialysis
session and the heparin anticoagulation during the following dialy-
sis session. Safety was determined on the basis of the changes in
blood electrolytes and acid-base homeostasis as well as cardiovas-
cular hemodynamics (blood pressure, heart rate). Effectiveness was
measured by a decrease in blood urea during dialysis and the clot-
ting level of the hemofilter at the end of the dialysis session.
In order to achieve a normal anticoagulation status all antico-
agulation therapy was suspended for at least 6 h prior to each di-
alysis session.
Genius® High-Flux Hemodialysis
The Genius® dialysis system is a single-pass batch system (Fre-
senius Medical Care, Bad Homburg, Germany). The dialysate des-
ignated for one treatment session is stored in an air-free 75-liter
glass tank. The dialysate is prepared immediately prior to the de-
sired dialysis session by the dialysis team. Once the tank is filled,
the system becomes highly mobile, allowing dialysis therapy to take
place almost anywhere. The use of a rechargeable battery enables
treatment even without a power supply.
c36 Nephron Clin Pract 2004;98:c35–c40
The dialysate is composed of ultrapure water, providing a ster-
ile and pyrogen-free dialysate. Electrolyte and bicarbonate concen-
trations can be individually composed according to the demands
of the patient. Sterile, pre-packed bicarbonate and electrolyte con-
centrates at various concentrations are commercially available. A
double-sided roller pump simultaneously generates blood and di-
alysate flow in a ratio of 1: 1. Maximum blood flow is 300 ml/h,
minimum flow rate is 70 ml/h. Blood flow determines the overall
dialysis time that can range from 4 to 18 h. The arterial and venous
blood lines (Schlauchsystem-Set, Genius® 01, Fresenius Medical
Care AG) do not contain a bubble catcher or a venous drip cham-
ber, respectively, thus avoiding air/blood contact areas and reduc-
ing the thrombogenicity of the system.
The spent fluid is drained at the bottom of the tank while fresh
dialysate comes from the top of the reservoir. Due to differences in
temperature and fluid density, fresh and used dialysate do not mix
[8].
For this study a polysulfone membrane was used (F8 HPS, Fre-
senius Medical Care AG). Dialysate composition was as follows:
1.00 mmol/l Ca, 0.5 mmol/l Mg, 140 mmol/l Na, 3 mmol/l potas-
sium, 35 mmol/l HCO3, 113 mmol/l Cl, 5.5 mmol/l glucose, and
0.067 mmol/l citrate. Hydrochloric acid (2.2 mmol/l) was used for
pH adjustment.
The vascular access was obtained by a double-lumen 12-french
catheter inserted into either the internal jugular, femoral or subcla-
vian vein.
Citrate Anticoagulation Protocol
A 4% trisodium citrate solution (provided by the university
pharmacy, 100 ml containing sodium citrate 4.0 g, citric acid
34 mg in aqua ad inject.) was infused pre-filter at a initial rate of
180 ml/h. Blood flow rate was 200 ml/min. Post-filter ionized cal-
cium levels were used to assess the adequacy of anticoagulation.
Ionized calcium was measured by ion-selective electrodes (AVL
984-S Analysers, AVL Medical Instruments UK Ltd., Stone, UK).
The citrate infusion was titrated to maintain the post-filter ion-
ized calcium level between 0.6 and 0.7 mmol/l. Post-filter ionized
calcium levels were obtained 15 min after treatment initiation
(T15), at the end of treatment (TE), and up to four times during the
treatment. There was no routine calcium chloride supplementa-
tion. For study purposes also pre-filter ionized calcium values were
measured. Samples were taken from the arterial port.
A diagram of the citrate anticoagulated Genius® dialysis system
is displayed in figure 1.
Heparin Anticoagulation
A single bolus of 1,000 IU heparin (Liquemin; Hoffmann-La
Roche AG, Grenzach-Wyhlen, Germany) was given into the arte-
rial port immediately after blood flow was initiated, followed by an
individual patient-adjusted continuous heparin infusion. An acti-
vated clotting time (ACT) of 140–180 s was targeted. The initial
heparin infusion rate was 500 IE/h. The ACT was measured hour-
ly. Whole blood ACT was analyzed with a coagulometer (Sigma-
Amelung, Lemgo, Germany) using kaolin as surface activator
(100 ng kaolin added to 0.3 ml whole blood).
Data Collection and Calculation
Dialysis system pressure, blood flow and ultrafiltration rates
were recorded hourly by the dialysis staff nurse. At the end of each
dialysis session, the nurse inspected the hemofilter for visible signs
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library
Morgera et al.
Downloaded by:
Fig. 1. Flow chart of the citrate anticoagu-
lated Genius® dialysis system.
of coagulation. An arbitrary 4-grade score with a range from 1 (no
signs of clotting) to 4 (complete occlusion) was used for evaluation.
Scores of 1 or 2 were considered to indicate good anticoagulation.
All data were recorded on the dialysis charts. A complete coagula-
tion status was obtained prior to each dialysis session. This includ-
ed the measurement of activated partial thromboplastin time, pro-
thrombin, thrombocyte count and hematocrit. In addition, a
thrombocyte function analysis was performed at the beginning of
the study using Dade® PFA-100® reagents (Dade Behring Marburg
GmbH, Marburg, Germany). The PFA-100® is an instrument and
test cartridge system in which the process of platelet adhesion and
aggregation following a vascular injury is simulated in vitro.
Samples for determination of sodium, potassium, chloride,
magnesium, total calcium, urea and creatinine were drawn at time
0 (T0) and at the end of the dialysis session (TE). Samples for the
determination of systemic ionized calcium and blood gas analysis
(pH, bicarbonate, base excess) were drawn into heparinized sy-
ringes and processed at the bedside at T0, T15, T60, T180 and ev-
ery 2 h until the end of treatment (TE).
Cardiovascular monitoring consisted of an invasive or nonin-
vasive blood pressure monitoring (systolic, diastolic and mean arte-
rial pressure) and heart rate.
Statistics
Analysis of variance models were used for comparison of the
two treatments. A paired two-tailed Student’s t test was used to
compare values before and at the end of the dialysis session for each
form of treatment separately. All data are expressed as mean 8
standard deviation. A p value of !0.05 is considered statistically
significant. The statistical program SPSS (SPSS Inc., Chicago, Ill.,
USA) was used for analysis.
Citrate Anticoagulation with the Genius®
Dialysis System
Results
Patient Characteristics
From the initial cohort of 27 patients recruited to the
study, 21 patients completed the study protocol receiving
both the citrate and the heparin anticoagulation protocol.
Six patients received only the citrate anticoagulation pro-
tocol. The main reason for these patients not completing
the study was their discharge from the intensive care unit.
Thus, 21 patients were considered for comparative anal-
yses.
The average age of the study population was 61 8 16
years, the body mass index was 24 8 4. All patients were
hemodynamically stable and free from vasopressive sup-
port. Fourteen patients were on ventilatory support.
Dialysis Efficiency and Cardiovascular
Hemodynamics
Plasma urea and creatinine concentrations during ci-
trate and heparin anticoagulation are given in table 1. The
calculated urea reduction rate was 53 8 12% for citrate
and 51 8 13% for heparin anticoagulation dialysis (p =
0.34, NS).
The hemodynamic status remained stable during Ge-
nius® dialysis. No differences were found between both
anticoagulation protocols. Systolic blood pressure and
heart rate at T0 were 133 8 30 mm Hg and 83 8 17
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library
Nephron Clin Pract 2004;98:c35–c40 c37
Downloaded by:
Table 1. Electrolytes, acid-base values, urea and creatinine values during citrate and heparin dialysis with the Genius® system

Citrate (n = 21) Heparin (n = 21) Intergroup

p value
T0 TE intragroup T0 TE intragroup
p value p value

Total calcium, mmol/l 2.2780.36 2.2480.39 0.432 – – – –

Systemic ionized calcium, mmol/l 1.1780.13 1.1580.06 0.272 – – – –
Chloride, mmol/l .10585 .10484 0.774 .10585 .10584 0.668 0.943
Sodium, mmol/l .13884 .13883 0.955 . .13984 .13983 0.407 0.874
Magnesium, mmol/l 1.0780.31 0.9480.19 0.041 0.9180.15 0.8680.11 0.124 0.244
Bicarbonate, mmol/l 24.283.1 26.882.3 0.000 24.182.5 25.581.3 0.012 0.026
pH 7.3580.04 7.3980.03 0.000 7.3680.04 7.4080.03 0.005 0.912
Urea, mg/dl .139863 1.70843 0.000 .134859 1.74854 0.000 0.843
Creatinine, mg/dl 4.8682.41 2.8081.20 0.000 4.6382.11 3.0281.65 0.000 0.913

Baseline values (T0) are compared to values obtained at the end of the dialysis session (TE).

beats/min for citrate dialysis and 135 8 29 mm Hg and Table 2. Coagulation parameters at baseline for citrate and heparin
84 8 17 beats/min for heparin dialysis. Corresponding dialysis
values at TE were 128 8 29 mm Hg and 87 8 17 beats/
Citrate Heparin p value
min for citrate and 129 8 30 mm Hg and 82 8 18 beats/ (n = 21) (n = 21)
min for heparin dialysis.
Prothrombin, % 182825 187824 0.475
Electrolytes and Acid-Base Balance Partial thromboplastin time, s 138811 13989 0.641
Thrombocytes, 106/µl 1958125 1978118 0.951
For both anticoagulation regimens, post-dialysis val- Hematocrit, % 12883 12982 0.320
ues for the electrolytes sodium, chloride and potassium Fibrinogen, mg/dl 4438173 4638148 0.841
were within the normal range. A significant treatment ef-
fect was detected for the magnesium levels during citrate
anticoagulation (significant decrease from baseline; p =
0.041). Total and ionized serum calcium levels remained
stable during citrate anticoagulation. The lowest ionized assay was normal in almost all patients. Five patients had
calcium level observed during citrate anticoagulation was thrombocyte dysfunction comparable to that induced by
0.98 mmol/l. aspirin (acetylic acid).
Blood pH, bicarbonate and base excess increased sig- The mean citrate infusion rate was 199 8 6 ml/h. Pre-
nificantly during both treatment modalities. The increase filter ionized calcium values were 0.18 8 0.05 mmol/l.
was slightly more pronounced during citrate anticoagula- Post-filter ionized calcium values during citrate antico-
tion. Final values for serum bicarbonate were greater with agulation were 0.67 8 0.07 mmol/l, and were thus with-
citrate as compared to heparin dialysis (p = 0.021). The in the desired range (0.6–0.7 mmol/l).
highest bicarbonate values observed were 29.1 mmol/l for In the heparin regime, a mean continuous heparin
citrate and 28.7 mmol/l for heparin anticoagulation. dose of 750 8 240 IU/h was achieved. The mean ACT
Electrolytes and acid base values before and at the end was 159 8 26 s. ACT values remained stable throughout
of the dialysis sessions are listed in table 1. the dialysis session. Figure 2 shows the ionized calcium
values and the ACT over time for both anticoagulation
Coagulation Status, Clotting Monitoring, Dialytic protocols.
Parameters and Filter Life Time Both dialysis sessions were comparable with respect to
The coagulation status was normal in all patients. Ta- blood flow rate and ultrafiltration rate. Both protocols
ble 2 shows baseline coagulation parameters for citrate achieved excellent filter longevity. Filter longevity did not
and heparin dialysis. The baseline thrombocyte function differ between citrate and heparin anticoagulation. Trans-
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library

c38 Nephron Clin Pract 2004;98:c35–c40 Morgera et al.

Downloaded by:
Table 3. Dialysis parameters during citrate
and heparin anticoagulation with the Citrate Heparin p value
Genius® dialysis system
Blood flow rate, ml/min 1.19885 (180–200) 1.205839 (180–280) 0.167
Ultrafiltration, ml 1,2408830 (0–3,200) 1,3208050 (0–3,600) 0.593
Targeted dialysis time, h 115.480.7 (4–6) 114.880.8 (3–6) 0.734
Achieved dialysis time, h 115.480.7 (4–6) 114.681.1 (3–6) 0.684
System pressure at T0, mm Hg 11.78827 (30–150) 11 82826 (50–150) 0.762
System pressure at TE, mm Hg 11.76824 (50–150) 11 81822 (60–130) 0.815

Values are expressed as mean 8 SD (range).

tients suffering from acute renal failure [9]. The Genius®

Fig. 2. Post-filter ionized calcium values and activated clotting
times during citrate and heparin anticoagulation with the Genius®
system.
membrane pressure remained stable during both antico-
agulation modalities (table 3).
Anticoagulation, as judged by visual inspection of the
extracorporeal system, was good in both groups. Com-
parative analyses revealed a slight advantage in favor of
heparin anticoagulation. Mean hemofilter clotting scores
were 1.8 8 0.8 for citrate and 1.5 8 0.5 for heparin (p =
0.038).
Discussion
The Genius® system – an innovative type of hemodi-
alysis equipment, originally developed by Bernd Terstee-
gen for chronic dialysis – has been introduced in many
intensive care units for the treatment of critically ill pa-
system can be used in an intermittent hemodialysis or
slow extended daily dialysis mode [9].
Here we provide a simple but very efficient citrate an-
ticoagulation protocol using a 4% trisodium-citrate solu-
tion in combination with a low calcium dialysate concen-
trate. No standard calcium substitution is required in this
protocol. We found that the citrate anticoagulation pro-
tocol is just as efficient as a standard heparin anticoagula-
tion regime.
Metabolic alkalosis, a frequent complication of citrate
anticoagulation, was not observed in our study. However,
the increase in serum bicarbonate and pH as well as the
peak concentrations achieved were statistically signifi-
cantly higher with our citrate anticoagulation protocol.
The absolute differences, however, were within the clini-
cally acceptable range. The tendency to metabolic alkalo-
sis could be easily overcome with a dialysis fluid contain-
ing less than the 35 mmol/l used in our study.
Citrate toxicity, namely hypocalcemia and hypercal-
cemia, was not observed. We used a standard dialysate
with a calcium concentration of 1 mmol/l and targeted
post-filter ionized calcium values between 0.6 and
0.7 mmol/l. As the calcium concentration at the filter out-
let was lower than the concentration of diffusible calcium
in the blood, a negative calcium balance of the dialysis
treatment had to be expected. However, regular controls
of the systemic ionized calcium concentrations were in
the normal range. Consequently, no calcium supplemen-
tation was required. We speculate that the calcium ho-
meostasis was kept equilibrated by physiological regula-
tory processes as well as through calcium recirculation
processes due to the hepatic metabolization of the calci-
um-citrate complexes (thus liberating free calcium ions).
However, we believe that calcium substitution may be-
come necessary when citrate anticoagulation is repeated
frequently.
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library

Citrate Anticoagulation with the Genius® Nephron Clin Pract 2004;98:c35–c40 c39
Dialysis System
Downloaded by:
 Systemic total calcium was not affected in our patients.
Hypercalcemia is well-known problem of citrate anti-
coagulation. It is often seen in patients with impaired
liver function [10, 11]. In these patients citrate metabo-
lization may be slowed down which may lead to citrate
accumulation, mainly as citrate-calcium complex. Also
magnesium may decline during citrate anticoagulation
as, similar to calcium, magnesium chelates with citrate.
In our study population a slight, but statistically signifi-
cant, decline in systemic magnesium values was observed.
This may have been facilitated by the relatively low mag-
nesium content of the dialysate (0.5 mmol/l). Should ci-
trate anticoagulation be used routinely, a supplementa-
tion of magnesium will likely be necessary (either
increasing the Mg content in the dialysate or by intrave-
nous Mg administration).
Hypernatremia may occur due to the administration
of high doses of sodium citrate. Hypernatremia was, how-
ever, not a problem in the present study. The use of a
dialysis fluid containing the relatively low sodium con-
centration of 135 mmol/l appropriately counteracted the
infusion of sodium with the citrate solution.
Citrate inhibits coagulation in a dose-dependent man-
ner which relies on a disturbed formation of the calcium-
dependent coagulation factor complexes. It has been
shown that ionized calcium values of !0.5 mmol/l are
necessary to achieve an anticoagulatory effect in the ex-
tracorporeal circuit [12]. Most clinical trials targeted for
post-filter ionized calcium values below this threshold
[13, 14]. In our study an ionized post-filter calcium value
of around 0.6–0.7 mmol/l was targeted. We observed very
good anticoagulatory effects. This phenomenon can only
be explained by the reduced thrombogenicity of the Ge-
nius® dialysis system compared to a standard hemodialy-
sis device (avoiding blood/air contact areas and eliminat-
ing the venous drip chamber).
The simplicity of our citrate anticoagulation protocol
permits a safe implementation of this anticoagulation
protocol for a selected group of patients. Especially for
those patients with a high risk of bleeding or those with
contraindications for the use of heparin, such as in hepa-
rin-induced thrombocytopenia type II.
Acknowledgement
This study was supported by a grant from Fresenius Medical
Care, Bad Homburg, Germany.

References

1 Tersteegen B, Van Endert G: Patent DE 31 15
665 A1, Bundesrepublik Deutschland, 1982.
2 Lonneman G, Floege J, Kliem V, et al: Extend-
ed daily veno-venous high-flux haemodialysis
in patients with acute renal failure and multi-
ple organ failure dysfunction syndrome using
a single path batch dialysis system. Nephrol
Dial Transplant 2000;15:1189–1193.
3 Fassbinder W: Renaissance of the batch meth-
od? Nephrol Dia Transplant 1998; 13: 3010–
3012.
4 Kleophas W, Backus G: A simplified method
for adequate hemodialysis. Blood Purif 2001;
19:189–194.
5 Remuzzi G: Bleeding in renal failure. Lancet
1988;105:1205–1208.
6 Magnani HN: Heparin-induced thrombocyto-
penia (HIT): An overview of 230 patients treat-
ed with orgaran (Org 10172). Thromb Hae-
most 1993;70:554–561.
7 Schwarz RD: Hemorrhage during high-risk he-
modialysis using controlled heparinization.
Nephron 1981;28:65–69.
8 Dhondt AW, Vanholder RC, De Smet RV, et
al: Studies on dialysate mixing in the Genius®
single-pass batch system for hemodialysis ther-
apy. Kidney Int 2003;63:1540–1547.
9 Kielstein JT, Kretschmer U, Ernst T, Hafer C,
Bahr MJ, Haller H, Fliser D: Efficacy and car-
diovascular tolerability of extended dialysis in
critically ill patients: A randomized controlled
study. Am J Kidney Dis 2004;43:342–349.
10 Diaz J, Acosta F, Parrilla P, et al: Correlation
among ionized calcium, citrate, and total cal-
cium levels during hepatic transplantation.
Clin Biochem 1995;28:315–317.
11 Meier-Kriesche HU, Gitomer J, Finkel K, Du-
Bose T: Increased total to ionized calcium ratio
during continuous venovenous hemodialysis
with regional citrate anticoagulation. Crit Care
Med 2001;29:748–752.
12 Calatzis A, Toepfer M, Schramm W, Spannagl
M, Schiffl H: Citrate anticoagulation for extra-
corporeal circuits: Effects on whole blood co-
agulation activation and clot formation. Neph-
ron 2001;89:233–236.
13 Mehta R, McDonald B, Aguilar M, Ward D:
Regional citrate anticoagulation for continu-
ous arteriovenous hemodialysis in critically ill
patients. Kidney Int 1990;38:976–981.
14 Tolwani AJ, Campbell RC, Schenk MB, Allon
M, Warnock DG: Simplified citrate anticoagu-
lation for continuous renal replacement thera-
py. Kidney Int 2001;60:370–374.
130.237.122.245 - 6/3/2015 10:53:29 AM
Karolinska Institutet, University Library

c40 Nephron Clin Pract 2004;98:c35–c40 Morgera et al.

Downloaded by: