Kutsogiannis D J, Mayers I, Chin W D, Gibney R T
Division of Critical Care Medicine, the University of Alberta, Edmonton, Canada.
Am J Kidney Dis. 2000 May;35(5):802-11. doi: 10.1016/s0272-6386(00)70248-4.
Over the past several years, continuous venovenous hemodiafiltration (CVVHDF) using pump-driven devices has gained wide acceptance as a form of renal replacement therapy for critically ill patients with acute renal failure. More recently, regional citrate anticoagulation has proven useful as a method of anticoagulating CVVHDF circuits, particularly in those patients at high risk for bleeding. However, an easy and convenient method for guiding the dose of citrate infusion has not previously been described. We describe the use of an algorithm using posthemofilter levels of ionized calcium to guide the dose of administered regional citrate on the survival time and urea and creatinine clearances of 24 Hospal AN69HF hemofilters. Nine patients with acute and chronic renal failure requiring CVVHDF were studied. The median filter survival time when using the postfilter ionized calcium algorithm was 3.4 days, with a survival probability of 46% (95% confidence interval [CI], 17 to 71). Random-effects linear regression analysis did not show a significant decline in blood-side urea clearance (P = 0.041) or creatinine clearance (P = 0. 308). Moreover, definite bleeding complications occurred with an incidence rate of 0.045/person-day on citrate anticoagulation (95% CI, 0.006 to 0.16), and occult bleeding occurred with an incidence rate of 0.091/person-day on citrate anticoagulation (95% CI, 0.03 to 0.23). Guiding regional citrate anticoagulation through the use of posthemofilter ionized calcium levels is a safe and effective method of prolonging filter life during CVVHDF.
在过去几年中，使用泵驱动设备的持续静脉-静脉血液透析滤过（CVVHDF）作为急性肾衰竭危重症患者的一种肾脏替代治疗方式已被广泛接受。最近，局部枸橼酸盐抗凝已被证明是一种用于CVVHDF回路抗凝的有效方法，尤其是在那些有高出血风险的患者中。然而，此前尚未描述一种简单便捷的方法来指导枸橼酸盐输注剂量。我们描述了一种算法的应用，该算法利用滤器后离子钙水平来指导局部枸橼酸盐的给药剂量，观察其对24个Hospal AN69HF血液滤器的生存时间以及尿素和肌酐清除率的影响。对9例需要CVVHDF的急慢性肾衰竭患者进行了研究。使用滤器后离子钙算法时，滤器的中位生存时间为3.4天，生存概率为46%（95%置信区间[CI]，17%至71%）。随机效应线性回归分析未显示血侧尿素清除率（P = 0.041）或肌酐清除率（P = 0.308）有显著下降。此外，枸橼酸盐抗凝时明确的出血并发症发生率为0.045/人日（95% CI，0.006至0.16），隐匿性出血发生率为0.091/人日（95% CI，0.03至0.23）。通过使用滤器后离子钙水平来指导局部枸橼酸盐抗凝是一种在CVVHDF期间延长滤器寿命的安全有效方法。
