华西医学

华西医学

简化枸橼酸抗凝技术在持续缓慢低效血液透析中的临床应用

查看全文

目的 观察简化枸橼酸抗凝技术应用于持续缓慢低效血液透析(sustained low efficiency dialysis,SLED)中的安全性及有效性。 方法 前瞻性分析四川大学华西医院肾脏内科 2017 年 3 月—2018 年 5 月收治的急性肾损伤或终末期肾脏疾病患者,均进行简化枸橼酸抗凝的 SLED 治疗模式。所有患者血管通路采用颈内/股静脉留置双腔导管,机器采用费森尤斯 4008s ARrTplus,治疗时间为 8~10 h,4% 的枸橼酸抗凝剂以 300 mL/h 的速度由动脉端泵入,治疗结束前 15 min 停止枸橼酸泵入。起始血流量为 150 mL/min,低钙透析液(钙 1.25 mmol/L)200 mL/min。在 0、2、6 h 分别测定外周血及滤器后游离钙水平及枸橼酸浓度。 结果 62 例患者共完成 185 例次 SLED 治疗,除 2 例患者在治疗过程中共发生 3 次滤器凝血(4~7 h)提前终止治疗外,余 182 例次(98.4%)SLED 治疗均顺利完成。患者治疗过程中,2、6 h 外周血枸橼酸浓度无明显差异[(0.82±0.31)vs.(0.86±0.31) mmol/L,P=0.21],0、2、6 h 的外周血游离钙水平分别为(1.12±0.21)、(1.09±0.12)、(1.11±0.09) mmol/L,差异无统计学意义(P>0.05);2、6 h 滤器后游离钙水平分别为(0.35±0.06)、(0.31±0.04) mmol/L;2、6 h 的跨膜压分别是(106.2±13.8)、(105.3±22.4)mm Hg(1 mm Hg=0.133 kPa),差异无统计学意义(P=0.42)。6 h 测定外周血凝血酶原时间及活化部分凝血酶时间与治疗前差异无统计学意义(P>0.05)。在 SLED 治疗过程中 4 例次(2.2%)患者出现轻度代谢性碱中毒,均在治疗结束 4 h 后恢复。治疗过程中未出现出血、血小板减少、心律失常、高钠血症及低血压事件。 结论 简化枸橼酸抗凝技术在 SLED 应用中安全有效,在使用常规含钙透析液的前提下仍然能够充分抗凝,并且不影响体内的凝血功能,为临床医生提供了一种新型的 SLED 抗凝方式。

Objective To evaluate the safety and efficacy of simplified regional citrate anticoagulation in sustained low efficiency dialysis (SLED). Methods We prospectively analyzed the patients with acute kidney injury or end stage renal disease in Department of Nephrology, West China Hospital of Sichuan University from March 2017 to May 2018. All the patients received SLED treatment by Fresenius 4008s ARrTplus through either femoral or internal jugular venous catheter, with each session of SLED treatment lasting for 8 to 10 hours. We pumped in 4% tri-sodium citrate solution through the arterial line at 300 mL/h and citrate infusion was stopped 15 minutes before ending of treatment. The blood flow was 150 mL/min while the calcium-containing dialysate (Ca 1.25 mmol/L) was delivered at 200 mL/min. We recorded peripheral, post filter ionized calcium level, and systemic citrate concentration at 0, 2 and 6 hours, respectively. Results Sixty-two patients underwent 185 sessions of SLED. Three sessions of two patients were discontinued for filter clotting, while the rest 182 SLED sessions (98.4%) were all successfully completed. The systemic citrate concentrations at 2 and 6 hours after beginning were of no statistical difference [(0.82±0.31) vs. (0.86±0.31) mmol/L, P=0.21]. The 0-, 2-, 6-hour peripheral blood ionized calcium levels were (1.12±0.21), (1.09±0.12), and (1.11±0.09) mmol/L, respectively, with no significant difference (P>0.05), and post filter ionized calcium at 2 and 6 hours after beginning were recorded as (0.35±0.06) and (0.31±0.04) mmol/L. The trans-membrane pressure at 2 and 6 hours after beginning were (106.2±13.8) and (105.3±22.4) mm Hg (1 mm Hg=0.133 kPa), with no significant difference (P=0.42). At 6 hours after beginning, prothrombin time and activated partial thrombin time were identified to be similar to those before SLED. During SLED treatments, in 4 sessions (2.2%), patients suffered mild metabolic alkalosis, but all of them recovered 4 hours later by themselves. No bleeding complication, thrombocytopenia, cardiac arrhythmia, hypernatremia, metabolic alkalosis or hypotension was observed. Conclusion SLED under simplified citrate anticoagulation is safe and effective by using calcium containing dialysate, which achieves satisfying regional anticoagulation effect without interfering systemic clotting function, and provides a new option of anticoagulation for SLED.

关键词: 持续缓慢低效血液透析; 枸橼酸; 抗凝; 含钙透析液

Key words: Sustained low efficiency dialysis; Citrate; Anticoagulation; Calcium-containing dialysate

引用本文: 张凌, 李佩芸, 魏甜甜, 杨莹莹, 陈志文, 林丽, 付平. 简化枸橼酸抗凝技术在持续缓慢低效血液透析中的临床应用. 华西医学, 2018, 33(7): 838-842. doi: 10.7507/1002-0179.201807011 复制

登录后 ,请手动点击刷新查看全文内容。 没有账号,
登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. 付平, 张凌. 杂合肾脏替代治疗的临床应用. 中国血液净化, 2011, 10(1): 7-9.
2. Zhang L, Yang J, Eastwood GM, et al. Extended daily dialysis versus continuous renal replacement therapy for acute kidney injury: a meta-analysis. Am J Kidney Dis, 2015, 66(2): 322-330.
3. 王婷立, 张凌, 陈志文, 等. 枸橼酸抗凝在持续缓慢低效血液透析中的应用. 中华内科杂志, 2014, 53(12): 953-956.
4. 张凌, 王婷立, 赵宇亮, 等. 枸橼酸抗凝在持续缓慢低效血液透析中的疗效及安全性. 中华内科杂志, 2013, 52(6): 459-463.
5. Zhang L, Liao Y, Xiang J, et al. Simplified regional citrate anticoagulation using a calcium-containing replacement solution for continuous venovenous hemofiltration. J Artif Organs, 2013, 16(2): 185-192.
6. Mishra SB, Azim A, Prasad N, et al. A pilot randomized controlled trial of comparison between extended daily hemodialysis and continuous veno-venous hemodialysis in patients of acute kidney injury with septic shock. Indian J Crit Care Med, 2017, 21(5): 262-267.
7. Kitchlu A, Adhikari N, Burns KE, et al. Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: a cohort study. BMC Nephrol, 2015, 16: 127.
8. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012, 120(4): C179-C184.
9. Chawla LS, Bellomo R, Bihorac A, et al. Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol, 2017, 13(4): 241-257.
10. van de Wetering J, Westendorp RG, van der Hoeven JG, et al. Heparin use in continuous renal replacement procedures: the struggle between filter coagulation and patient hemorrhage. J Am Soc Nephrol, 1996, 7(1): 145-150.
11. Martin PY, Chevrolet JC, Suter P, et al. Anticoagulation in patients treated by continuous venovenous hemofiltration: a retrospective study. Am J Kidney Dis, 1994, 24(5): 806-812.
12. 赵宇亮, 张凌, 付平. 枸橼酸抗凝在肾脏替代治疗中的新进展. 中华内科杂志, 2012, 51(7): 571-573.