Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
J Nephrol. 2012 Jan-Feb;25(1):113-9. doi: 10.5301/JN.2011.8363.
Regional citrate anticoagulation (RCA) is being used increasingly in critically ill patients who require continuous renal replacement therapy (CRRT). RCA may be avoided in patients with liver disease because of perceived increased risk of metabolic complications. The study compares the circuit lifespan and metabolic complications using RCA for CRRT at varying levels of liver dysfunction.
Data was collected retrospectively including the number of days on CRRT, number of circuit (re)initiations within that time and serum ionized and total calcium, bicarbonate, and sodium, repeatedly during treatment. Model for end-stage liver disease (MELD) scores were calculated and patients were divided into 4 groups according to MELD score quartiles.
A total of 697 patients were included in the present study. The median circuit survival time was not different between groups. The median minimum serum ionized calcium levels during treatment were significantly lower in groups 3 and 4 (p<0.001), but by the last day of treatment, mean serum ionized calcium levels were not different between groups. The median minimum bicarbonate levels were significantly lower in groups 3 and 4 compared with groups 1 and 2 (p<0.01), but this is not considered clinically significant. The median maximum and mean serum bicarbonate levels were not significant between groups. Total to ionized calcium ratio levels were similar in groups 1, 2 and 3, but significantly higher in group 4 compared with other groups.
RCA is a reasonably safe form of anticoagulation for maintaining efficiency and patency of the dialyzer in critically ill patients with liver dysfunction.
在需要持续肾脏替代治疗（CRRT）的危重症患者中，越来越多地使用局部枸橼酸抗凝（RCA）。由于代谢并发症风险增加，肝功能障碍的患者可能避免使用 RCA。本研究比较了不同肝功能障碍程度下使用 RCA 进行 CRRT 的回路寿命和代谢并发症。
回顾性收集数据，包括 CRRT 的天数、在此期间重新启动的回路次数以及治疗过程中反复测量的血清离子钙和总钙、碳酸氢盐和钠。计算终末期肝病模型（MELD）评分，并根据 MELD 评分四分位数将患者分为 4 组。
本研究共纳入 697 例患者。各组间回路生存时间中位数无差异。治疗期间最低血清离子钙水平中位数在第 3 组和第 4 组显著降低（p<0.001），但治疗最后一天，各组间平均血清离子钙水平无差异。第 3 组和第 4 组的最低碳酸氢盐水平中位数显著低于第 1 组和第 2 组（p<0.01），但这在临床上无显著意义。各组间最大和平均血清碳酸氢盐水平中位数无显著差异。第 1 组、第 2 组和第 3 组的总钙与离子钙比值水平相似，但第 4 组显著高于其他组。
对于肝功能障碍的危重症患者，RCA 是一种合理安全的抗凝方式，可维持透析器的效率和通畅性。
