摘要
目的比较存有高出血风险因素的急性。肾损伤患者行连续性肾脏替代治疗（continuous renal replacement therapy, CRRT）时使用局部枸橼酸抗凝（regional citrate anticoagulation,RCA）和无抗凝模式间的优缺点。方法患者达到改善全球肾脏病预后组织标准的急性肾损伤3期，同时并存高出血风险因素，如大手术后、凝血功能紊乱（凝血酶原时间、活化部分凝血活酶时间大于正常值的1．5倍或凝血酶原时间〉18s，活化部分凝血活酶时间〉60s）、血小板减少（〈50×10^9／L），合并使用抗凝、抗血小板、溶栓药物等；随机（随机数字法）分为无抗凝组和RCA组后4h内完成上机。排除严重肝功能衰竭（血总胆红素〉171μmol／L）患者。两组均采用持续性静脉静脉血液透析滤过模式，滤器常规72h更换，除非管路凝结。因目前国内尚无商品化的无钙透析液，故此透析液由本单位自行配置。结果两组各有16例患者纳入研究，多为外科术后，组间年龄、性别比，及并存高血压、2型糖尿病与慢性肾功能不全的比例差异无统计学意义。患者行CRRT前后的血气、肝肾功能、凝血功能、电解质、血红蛋白、血小板等在两组间差异无统计学意义。通过Kaplan—Meier曲线分析，RCA组患者行CRRT时其单个滤器使用时间较无抗凝组更长（χ^2=9．707，P=0．002）；单个滤器使用的时间（h）为36．01（26．61—45．42）和22．04（18．35～25．73）。无抗凝组在CRRT期间较RCA组需输更多的浓缩红细胞量与血小板量（P=0．04）。RCA组与无抗凝组患者重症加强治疗病房（ICU）内病死率差异无统计学意义（7／16和9／16，P=0．724）。两组患者行CRRT期间均未发生严重失血与恶性心律失常事件。RCA组行CRRT期间，体温与血电解质基本维持在正常生理范围，滤器后血离子钙水平及机体血总钙／离子钙比例在目标范围内。结论高出血风险急性肾损伤患者行CRRT时，RCA模式安全、有效，较无抗凝模式能延长滤器使用时间及降低失血风险，但未改善患者ICU内存活率，同时国内目前情况下RCA模式会增加护士工作量。
Objective To explore the advantages and disadvantages of regional citrate anticoagulation （RCA） mode by comparing to non-anticoagulation mode for continuous renal replacement therapy （CRRT） in patients with acute kidney injury （AKI） at high risk of bleeding. Methods The criterion for inclusion of patients was stage 3 of AKI selected according to Kidney Disease Improving Global Outcomes guideline. And those patients had high risk factors of bleeding as well as such as post-major opertion, coagulopathy （prothrombin time or activated partial thromboplastin time 〉 1.5 times the normal control, or prothrombin time 〉 18 s, activated partial thromboplastin time 〉 60 s）, thrombocytopenia （ 〈 50 × 10^9/L） , and combined therapy with anticoagulant, antiplatelet or thrombolytic drugs. The CRRT was initiated within 4 h after randomization. The exclusion criteria was severe liver failure （ serum total bilirubin 〉 171 μmmol/L）. Continuous venovenous hemodiafihration mode was employed in both groups, and the filter was changed routinely every 72 h, unless clotting developed in the extracorporeal circuit. Because the commercial calcium-free dialysate was not available in the market, this dialysate was prepared by the intensive care unit （ICU） nurses. Results Thirty two patients were equally divided in those two groups, and most of them were admitted to ICU after major surgery. There were no significant differences between the groups in data of blood gas analysis, hepatic/renal/coagulative functions, electrolyte, hemoglobin and platelet count before or after CRRT. The filter was more durable in RCA mode than that in non-RCA mode determined through Kaplan-Meier curve analysis （χ^2= 9. 707, P = 0. 002）, with the mean time （h） 36. 01 （26. 61 -45.42） vs. 22. 04 （18. 35- 25.73 ）. More packed red blood cells and platelet were required in non-RCA mode than those in RCA mode during CRRT. There was no significant difference in ICU mortality between RCA mode and non-RCA mode with 7/16 vs. 9/16, P = 0. 724. Severe blood loss and malignant arrhythmia events did not occur in both modes. The body temperature, systemic electrolyte, post-filter ionized calcium levels and the ratio of total to ionized systemic calcium were basically preserved at a target range in RCA group during CRRT. Conclusions RCA-CRRT is a safe and effective mode for AKI patient with high risk of bleeding, which can extend the durability of filter, and lower the risk of blood loss. However, the study failed to show a mortality benefit with the RCA mode, and it could also increase the workload of nurses under the current domestic setting.
出处
《中华急诊医学杂志》
CAS
CSCD
北大核心
2017年第9期1020-1026,共7页
Chinese Journal of Emergency Medicine
基金
浙江省教育厅科研项目（Y201636226）
