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枸橼酸抗凝在危重症连续性肾脏替代治疗中的应用。

Citrate anticoagulation for continuous renal replacement therapy in the critically ill.

机构信息

Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

出版信息

Blood Purif. 2010;29(2):191-6. doi: 10.1159/000245646. Epub 2010 Jan 8.

Abstract

BACKGROUND

Heparins are used for circuit anticoagulation during continuous renal replacement therapy (CRRT). Because heparins cause systemic anticoagulation, they increase the risk of bleeding. Citrate provides regional anticoagulation. Since citrate is a buffer as well, its use has metabolic consequences. The preferential use of citrate therefore remains controversial.

METHODS

A synthesis was performed of published studies comparing citrate to heparin for anticoagulation in CRRT with specific regard to feasibility, efficacy and safety. Search of the literature was made to explain the reported superiority of citrate.

RESULTS

Citrate provides good metabolic control if and when a well-designed protocol is strictly followed. Randomized studies report similar or longer circuit survival with citrate compared to heparin and less bleeding. The largest randomized trial up to now found that citrate was better tolerated than heparin and improved patient and kidney survival, especially in patients after surgery, with sepsis, a high degree of organ failure or younger age. Both citrate and heparin interfere with inflammation.

CONCLUSION

During critical illness, regional anticoagulation with citrate for CRRT seems superior to heparin anticoagulation concerning tolerance and safety, mainly due to less bleeding. Whether circuit survival is better depends on the modality. In addition, citrate seems to improve patient and kidney survival. This finding needs to be confirmed. Citrate seems to confer a specific benefit in severe organ failure and sepsis. To what extent citrate protects or heparin does harm in the setting of multiple organ failure needs to be unraveled.

摘要

背景

肝素用于连续肾脏替代治疗(CRRT)中的回路抗凝。由于肝素会引起全身抗凝,因此会增加出血的风险。柠檬酸盐提供局部抗凝。由于柠檬酸盐也是一种缓冲剂,因此其使用会产生代谢后果。因此,优先使用柠檬酸盐仍然存在争议。

方法

对已发表的研究进行了综合分析,这些研究比较了柠檬酸盐与肝素在 CRRT 中的抗凝效果,特别关注其可行性、疗效和安全性。搜索文献以解释报告中柠檬酸盐优越性的原因。

结果

如果严格遵循精心设计的方案,柠檬酸盐可提供良好的代谢控制。随机研究报告表明,与肝素相比,柠檬酸盐具有相似或更长的回路寿命,且出血更少。到目前为止,最大的随机试验发现,与肝素相比,柠檬酸盐的耐受性更好,并改善了患者和肾脏的存活率,特别是在手术后、脓毒症、高器官衰竭或年轻的患者中。柠檬酸盐和肝素均会干扰炎症。

结论

在危重病期间,使用柠檬酸盐进行 CRRT 的局部抗凝似乎优于肝素抗凝,这主要是由于出血减少。回路寿命是否更好取决于治疗方式。此外,柠檬酸盐似乎可以改善患者和肾脏的存活率。这一发现需要进一步证实。在严重器官衰竭和脓毒症中,柠檬酸盐似乎具有特定的益处。在多器官衰竭的情况下,柠檬酸盐是否具有保护作用,而肝素是否有害,这需要进一步阐明。

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