使用枸橼酸盐置换液的持续静脉-静脉血液滤过：疗效、安全性及对营养的影响

Continuous venovenous hemofiltration with citrate-based replacement fluid: efficacy, safety, and impact on nutrition.

作者信息

Bihorac Azra, Ross Edward A

机构信息

Division of Nephrology, Hypertension, and Transplantation, University of Florida, Gainesville, FL 32610-0224, USA.

出版信息

Am J Kidney Dis. 2005 Nov;46(5):908-18. doi: 10.1053/j.ajkd.2005.08.010.

DOI:10.1053/j.ajkd.2005.08.010

PMID:16253732

Abstract

BACKGROUND

Citrate-based continuous venovenous hemofiltration (CVVH) replacement fluids provide effective and simple regional anticoagulation. However, concern over toxicity has limited citrate use, especially at the high filtration rates advocated for better outcomes. We used volumes of 72 L/d in patients at high risk for bleeding and investigated the treatment's efficacy, safety, and clinical results, especially with regard to nutrition supplementation.

METHODS

A standard replacement solution (trisodium citrate, 13.3 mmol/L) was infused at up to 3 L/h in predilution CVVH, and ultrafiltration was increased further for net fluid removal. Calcium was repleted centrally. We retrospectively evaluated metabolic control, citrate toxicity, circuit patency, hemorrhagic complications, hemodynamics, vasopressor use, nutrition, renal recovery, and mortality.

RESULTS

Seventy-six patients with 766 CVVH patient-days were analyzed. Mean replacement fluid rate was 31 mL/kg/h (35 mmol/h of citrate), with hemofiltration of 35 mL/kg/h (67 +/- 11 L/d). No significant bleeding, citrate toxicity, or hypocalcemia was observed, and 74% required additional alkali therapy. Dialyzer patency was 58% at 48 hours. Control of fluid, electrolytes, and azotemia was excellent (serum creatinine level, 1.7 mg/dL [150 micromol/L]; blood urea nitrogen, 42 mg/dL [15 mmol/L]). Fluid removal permitted protein (1.7 g/kg/d) and calorie (30 kcal/kg/d) nutrition in high fluid volumes. Vasopressor use and central pressures decreased significantly. Cumulative 28-day intensive care unit survival was 58%, and 41% of these patients had renal recovery in the intensive care unit. Thirty percent of the entire cohort survived the hospitalization, and 53% of these patients recovered renal function.

CONCLUSION

CVVH with 3 L/h of citrate-based replacement fluid is a safe, efficient, and simple technique in patients at high risk for bleeding. It allows superb control of uremia and fluid balance and thereby permits aggressive nutritional support.

摘要

背景

基于枸橼酸盐的连续性静脉-静脉血液滤过（CVVH）置换液可提供有效且简便的局部抗凝。然而，对其毒性的担忧限制了枸橼酸盐的使用，尤其是在为获得更好疗效而提倡的高滤过率情况下。我们对出血高风险患者使用了72 L/d的置换液量，并研究了该治疗方法的疗效、安全性及临床结果，尤其是在营养补充方面。

方法

在预稀释CVVH中，以高达3 L/h的速度输注标准置换液（枸橼酸钠，13.3 mmol/L），并进一步增加超滤以实现净液体清除。通过中心静脉补充钙剂。我们回顾性评估了代谢控制、枸橼酸盐毒性、滤器通畅情况、出血并发症、血流动力学、血管升压药使用情况、营养状况、肾功能恢复及死亡率。

结果

分析了76例患者共766个CVVH患者日。平均置换液速率为31 mL/kg/h（枸橼酸盐35 mmol/h），血液滤过速率为35 mL/kg/h（67±11 L/d）。未观察到明显出血、枸橼酸盐毒性或低钙血症，74%的患者需要额外的碱治疗。48小时时透析器通畅率为58%。液体、电解质和氮质血症控制良好（血清肌酐水平1.7 mg/dL [150 μmol/L]；血尿素氮42 mg/dL [15 mmol/L]）。大量液体清除使患者能够摄入蛋白质（1.7 g/kg/d）和热量（30 kcal/kg/d）进行营养支持。血管升压药使用及中心静脉压显著降低。28天重症监护病房累积生存率为58%，其中41%的患者在重症监护病房实现肾功能恢复。整个队列中30%的患者住院期间存活，其中53%的患者肾功能恢复。