The optimal anticoagulation procedure during MARS treatment has not been defined. In various
multi-centre trials, such as MARS-RELIEF, anticoagulation procedures are left to the
discretion of the treating physician. On the one hand, given the increased risk of bleeding
associated with liver failure, high dosage of anticoagulation therapy should be avoided. On
the other hand, contact of blood or blood components with the extracorporeal circuit will
likely result in coagulation activation or even loss of coagulation factors.
Citrate anticoagulation has gained popularity, especially in hemodialysis patients. It
results in a highly effective anticoagulation, exclusively confined to the extracorporeal
circulation. Moreover, dependent on the type of dialyser membrane, citrate anticoagulation
resulted in reduced activation of other cellular components.
In contrast to hemodialysis patients, experience with citrate anticoagulation during
treatment with artificial liver devices is limited. The liver contributes substantially to
the metabolism of exogenous citrate. As a result, cirrhotic patients have decreased
endogenous citrate clearances. Importantly, blood purification devices contribute
substantially to overall citrate clearance, thereby preventing accumulation of citrate.
Several centres, including our own, have gained experience with citrate anticoagulation
during fractionated plasma separation and adsorption (FPSA), a related liver dialysis device,
in the treatment of liver failure patients.
Citrate anticoagulation during MARS treatment has not been studied so far.