Department of Nephrology, Fremantle Hospital, Perth, Western Australia, Australia.
Nephrology (Carlton). 2011 May;16(4):396-402. doi: 10.1111/j.1440-1797.2010.01421.x.
Haemodialysis with regional citrate anticoagulation in patients with contraindications for heparin is increasingly performed in the USA and Europe. Most published protocols use trisodium citrate, which is not readily available nor is it licensed in Australia. We established a protocol for citrate-anticoagulation in haemodialysis using acid citrate dextrose solution A (ACDA), which is approved for apheresis procedures in Australia. The aim of the present study was to assess the safety and efficacy of this protocol for routine use in haemodialysis patients.
Systemic and post-filter blood ionized calcium, serum sodium and bicarbonate and dialyzer clotting score were analyzed prospectively in 14 patients undergoing 150 consecutive haemodialysis treatments with citrate anticoagulation using calcium-free dialysate. A simple algorithm allowed the attending nurse to adjust citrate infusion (to maintain post-filter ionized calcium at 0.2-0.3 mmol/L) and i.v. calcium substitution. Scheduled dialysis time was 4 h, and point-of-care monitoring of blood ionized calcium during dialysis was done at 0, 15, 60, 120 and 240 min.
ACDA infusion rates of 300 mL/h were used in the first 52 treatments, but resulted in high dialyzer clotting score and 6% of treatments were discontinued due to complete clotting. Thereafter, ACDA infusion rate was increased to 350 mL/h, with all 98 subsequent treatments completed successfully. Ionized calcium levels were stable during all procedures with post-dialysis serum sodium averaging 135 ± 3 mmol/L and bicarbonate 23.8 ± 2 mmol/L.
Routine use of citrate anticoagulation in the setting of a long-term haemodialysis unit is safe and efficient. Point-of-care measurements of ionized calcium levels are critical to safely and successfully perform citrate anticoagulation.
在美国和欧洲，越来越多的患者因肝素使用禁忌而接受局部枸橼酸钠抗凝的血液透析。大多数已发表的方案都使用枸橼酸钠三钠，但这种药物在澳大利亚既不易获得也未获得许可。我们制定了一个使用澳大利亚批准用于血浆分离术的柠檬酸葡萄糖酸盐 A（ACD）进行血液透析枸橼酸盐抗凝的方案。本研究旨在评估该方案在常规血液透析患者中的安全性和有效性。
前瞻性分析 14 例患者在 150 次连续血液透析中使用无钙透析液进行枸橼酸钠抗凝的情况，观察 14 例患者的全身和滤器后血离子钙、血清钠和碳酸氢盐以及透析器凝血评分。采用简单的算法，让值班护士调整枸橼酸钠输注（维持滤器后离子钙在 0.2-0.3mmol/L）和静脉补钙。计划透析时间为 4 小时，在透析过程中实时监测血液离子钙，在 0、15、60、120 和 240 分钟时进行检测。
在最初的 52 次治疗中，ACD 输注速度为 300ml/h，但导致透析器凝血评分高，6%的治疗因完全凝血而中断。此后，将 ACD 输注速度增加到 350ml/h，随后 98 次治疗均成功完成。所有程序中离子钙水平均保持稳定，透析后血清钠平均为 135±3mmol/L，碳酸氢盐为 23.8±2mmol/L。
在长期血液透析中心常规使用枸橼酸钠抗凝是安全有效的。离子钙水平的即时检测对安全、成功地进行枸橼酸钠抗凝至关重要。
