van der Meulen J, Janssen M J, Langendijk P N, Bouman A A, Oe P L
Nephrology Unit, Free University Hospital, Amsterdam, The Netherlands.
Clin Nephrol. 1992 Jan;37(1):36-41.
Anticoagulation with trisodium citrate (510 mmol/l) at a rate of 126 ml/h in combination with a calcium-free, 35 mmol/l acetate dialysate and i. v. supplementation of calcium chloride (350 mmol/l) at a rate of 22.5 ml/h has been performed in renal failure patients at risk of bleeding or actively bleeding. Short-term use-i. e. on the average four dialyses in 15 patients-showed no adverse effects or clotting phenomena. However, long-term use-i. e. at least four weeks and on average sixteen dialyses in six chronic hemodialysis patients-caused paresthesias and muscular cramps possibly due to the combination of insufficient calcium supplementation and metabolic alkalosis. To prevent metabolic alkalosis, the acetate content of the dialysate and the infusion rate of citrate were reduced to 29.5 mmol/l and 100 ml/h, respectively. To prevent clotting at this infusion rate, a calcium and magnesium-free dialysate was used and i. v. supplementation of calcium chloride (350 mmol/l) and magnesium chloride (250 mmol/l) was performed at rates of 30 ml/h and 15 ml/h, respectively. Six chronic renal failure patients were dialyzed with this regimen for an average of four months. There were no side effects or metabolic alkalosis noted. When an equimolar amount of bicarbonate replaced the acetate in the calcium and magnesium-free dialysate, side effects and metabolic alkalosis were seen within three dialyses. When the bicarbonate concentration in the dialysate was reduced to 25 mmol/l neither side effects nor metabolic alkalosis was observed. Thus citrate anticoagulation in patients on chronic hemodialysis can only be performed when the buffer content of the dialysate is reduced.
对于有出血风险或正在出血的肾衰竭患者，采用柠檬酸钠（510 mmol/l）以126 ml/h的速度进行抗凝，同时使用不含钙、含35 mmol/l醋酸盐的透析液，并以22.5 ml/h的速度静脉补充氯化钙（350 mmol/l）。短期使用——即15名患者平均进行4次透析——未显示出不良反应或凝血现象。然而，长期使用——即6名慢性血液透析患者至少使用四周且平均进行16次透析——导致了感觉异常和肌肉痉挛，可能是由于钙补充不足和代谢性碱中毒共同作用所致。为预防代谢性碱中毒，将透析液中的醋酸盐含量和柠檬酸盐输注速度分别降至29.5 mmol/l和100 ml/h。为防止在此输注速度下出现凝血，使用了不含钙和镁的透析液，并分别以30 ml/h和15 ml/h的速度静脉补充氯化钙（350 mmol/l）和氯化镁（250 mmol/l）。6名慢性肾衰竭患者采用该方案进行透析，平均时长为四个月。未观察到副作用或代谢性碱中毒。当在不含钙和镁的透析液中用等摩尔量的碳酸氢盐替代醋酸盐时，在三次透析内就出现了副作用和代谢性碱中毒。当透析液中的碳酸氢盐浓度降至25 mmol/l时，既未观察到副作用，也未出现代谢性碱中毒。因此，慢性血液透析患者只有在降低透析液缓冲成分含量时才能进行柠檬酸盐抗凝。
