the dose of dialysis in terms of urea clearance is marginal in many hemodialysis patients , and metabolic acidosis as determined by the pre - dialysis serum hco 3 level is common . a dialysate that included citric acid rather than acetic acid as acidifying agent provides superior performance properties . citrate - containing dialysate was used exclusively in 22 hemodialysis patients . initially , only 8 of the 22 patients had a pre - dialysis serum hco 3 & gt ; 23 meq / l , however , after 12 weeks of dialysis using the citrate - containing dialysate , the serum hco 3 normalized in 15 patients . dialysis variables were kept constant in 19 of the patients , who also used and reused the same dialyzer model throughout . in these patients , the initial average urea reduction ratio was 68 . 5 ± 5 . 9 %, and after treatment with the citrate dialysate disclosed herein , this ratio had increased to 73 ± 5 . 3 % . spkt / v , calculated using the daugirdas ii formula , also increased from 1 . 23 ± 0 . 19 to 1 . 34 ± 0 . 2 . this increased urea clearance may be the result of the anticoagulant property of citrate maintaining patency of the dialyzer membrane . the increase in pre - dialysis serum hco 3 may represent increased delivery from the dialysate and production from citric acid .