Lok Charmaine E, Appleton Debra, Bhola Cynthia, Khoo Brian, Richardson Robert M A
Department of Medicine, Division of Nephrology, The Toronto General Hospital, 11 EN-216, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
Nephrol Dial Transplant. 2007 Feb;22(2):477-83. doi: 10.1093/ndt/gfl570. Epub 2006 Oct 2.
Central venous catheters (CVCs) continue to be used at a high rate for dialysis access and are frequently complicated by thrombus-related malfunction. Prophylactic locking with an anticoagulant, such as heparin, has become standard practice despite its associated risks. Trisodium citrate (citrate) 4% is an alternative catheter locking anticoagulant.
The objective was to prospectively study the clinical effectiveness, safety and cost of citrate 4% vs heparin locking by comparing rates of CVC exchanges, thrombolytic use (TPA) and access-associated hospitalizations during two study periods: heparin period (HP) (1 June 2003-15 February 2004) and Citrate Period (CP) 15 March-15 November 2004. Incident catheters evaluated did not overlap the two periods.
There were 176 CVC in 121 patients (HP) and 177 CVC in 129 patients (CP). The event rates in incident CVC were: CVC exchange 2.98/1000 days (HP) vs 1.65/1000 days (CP) (P = 0.01); TPA use 5.49/1000 (HP) vs 3.3/1000 days (CP) (P = 0.002); hospitalizations 0.59/1000 days (HP) vs 0.28/1000 days (CP) (P = 0.49). There was a longer time from catheter insertion to requiring CVC exchange (P = 0.04) and TPA (P = 0.006) in the citrate compared with the heparin lock group. Citrate locking costs less than heparin locking but a formal economic analysis including indirect costs was not done.
Citrate 4% has equivalent or better outcomes with regards to catheter exchange, TPA use and access-related hospitalizations compared with heparin locking. It is a safe and less expensive alternative. Randomized trials comparing these anticoagulants with a control group would definitively determine the optimal haemodialysis catheter locking solution.
中心静脉导管（CVC）仍被大量用于透析通路，且常因血栓相关故障而出现并发症。尽管存在相关风险，但使用抗凝剂（如肝素）进行预防性封管已成为标准做法。4%的枸橼酸钠是一种替代的导管封管抗凝剂。
目的是通过比较两个研究阶段（肝素阶段（HP）（2003年6月1日至2004年2月15日）和枸橼酸钠阶段（CP）2004年3月15日至11月15日）的CVC更换率、溶栓药物使用（TPA）和通路相关住院率，前瞻性地研究4%枸橼酸钠与肝素封管的临床有效性、安全性和成本。所评估的新置导管在两个阶段不重叠。
121例患者中有176根CVC（HP），129例患者中有177根CVC（CP）。新置CVC的事件发生率为：CVC更换率2.98/1000天（HP）对1.65/1000天（CP）（P = 0.01）；TPA使用率5.49/1000（HP）对3.3/1000天（CP）（P = 0.002）；住院率0.59/1000天（HP）对0.28/1000天（CP）（P = 0.49）。与肝素封管组相比，枸橼酸钠封管组从导管插入到需要更换CVC（P = 0.04）和TPA（P = 0.006）的时间更长。枸橼酸钠封管的成本低于肝素封管，但未进行包括间接成本在内的正式经济分析。
与肝素封管相比，4%枸橼酸钠在导管更换、TPA使用和通路相关住院方面具有同等或更好的效果。它是一种安全且成本更低的替代方法。将这些抗凝剂与对照组进行比较的随机试验将最终确定最佳的血液透析导管封管溶液。
