Concentrates BIC AF

After the introduction of dialysis concentrates acidified with citric acid with a small residual content of sodium acetate (Citrasate®) into clinical practice, acetate free concentrates BIC AF with citric acid represent another step towards the improvement in the characteristics of dialysis concentrates and the characteristics of the dialysis solution prepared from these concentrates.

The BIC AF concentrates are intended for on-line proportioning of the dialysis solution for intermittent bicarbonate haemodialysis (HD) and on-line haemodiafiltration (HDF). Dialysis therapy with these solutions is more efficient and shows, in general, higher biocompatibility than the therapy with conventional solution containing acetic acid. The BIC AF concentrates are used in the same way as the conventional ones.

In numerous studies, the concentrates with citric acid have shown a number of positive effects on the course of dialysis therapy and its outcomes with those effects being related to the replacement of acetic acid with citric acid.



Reduced thrombogenicity in the extracorporeal circuit as a consequence of local drop in the concentration of ionized calcium in the dialyser due to the formation of the calcium-citrate complexes.

- Possible considerable reduction in the doses of heparin, both unfractionated (1, 2, 3, 4) as well as low-molecular weight heparin (5), or even entirely heparin-free HD or HDF fully without heparin (6, 7, 8, 9, 10).

- Well applicable, namely in patients with heparin-induced thrombocytopenia (HIT) and after surgery (8, 10).

- An advantageous option for SLED doing away with the risk of excessive alkalinization of patient associated with regional citrate anticoagulation (10, 11, 12).

Immediately following the change-over to the citric acid-containing solution, the CRP level in plasma decreases (5, 13).

Minimum concentration of acetate in dialysate or its total absence there decreases pro-inflamatory effects of dialysis and leads to decreased production of IL-1, IL-6 and other proinflamatory cytokines in monocytes and polymorphonuclear neutrophiles during dialysis with citrate-containing dialysate (6, 14, 15, 16, 17, 18, 19, 20).

Also reduction in oxidative stress characterized by lower levels of myeloperoxidase (6, 21) has been documented in citrate dialysis.



Slight amelioration of dialysis efficiency (increase in spKt/V by 5-7%) has been found in a number of studies with citrate-containing dialysate (4,14,22), although some were not able to confirm this (23).



Formation of sediments in the hydraulic circuit of the dialysis machine is reduced due partial complexing of the calcium ions in dialysate (24).



Absence of acetate eliminates formation of nitric oxide and thus reduces possible vasodilatation (25).



It is advantageous in patients prone to arrhythmias (26). On the other side, some studies found increased incidence of hypotensions due to lower calcium balance during dialysis (26, 27). However, more frequent hypotensions were not seen in other studies (23), some have even reported improved overall haemodynamic stability with use of acetate-free dialysis solutions (28).



Lowered level of ionized calcium in plasma may lead to an increase in plasma iPTH during dialysis with citrate. Data on magnitude of this increase vary widely, ranging from a few percent (29) up to tens of percent (23). Review articles nevertheless indicate that there are no clinically significant changes in plasma iPTH and ionized and total calcium either in long-term perspective (1, 30).



Concentrates BIC AF are intended to carry out haemodialysis (HD) as well as on-line hemodiafiltration (HDF).

Moderate drop in plasma calcium level may appear with the conversion to these concentrates and the concentration of PTH (6) can increase. It is, therefore, advisable to use calcium concentration of 1.5 mmol/l (1, 2) together with the conversion to BIC AF concentrates in patients who were using conventional dialysis solution with calcium concentration of 1.25 mmol/l before the conversion.

BIC AF concentrates can be used on all common types of dialysis machines.




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Huang A, Sandholm K, Jonsson N, Nilssson A, Wieslander A, Grundström G, Hancock S, Nilsson- Ekdahl K: Low concentration of citrate reduce complement and granulocyte activation in vitro in human blood, Clin Kidney J, 2015, 8:31-37

Raimundo M, Crichton S, Lei K, Sanderson B, Smith J, Brooks J, Ng J, Lemnich Smith J: Maintaining normal levels of ionized calcium during citrate-based renal replacement therapy is associated with stable PTH, Nephron Clin Pract, 2013, 4:124-131