Morabito Santo, Pistolesi Valentina, Pierucci Alessandro
Universita' di Roma, Roma, Italy.
G Ital Nefrol. 2012 Jan-Feb;29(1):14-9.
Continuous renal replacement therapy (CRRT) is the most widely used technique for the treatment of severe acute kidney injury in the critically ill. The need for prolonged anticoagulation is the most important drawback of CRRT and clinically important bleeding significantly increases the risk of death. Therefore, alternative anticoagulation methods should be more widely adopted. Among the potential alternatives to systemic heparin anticoagulation, regional citrate anticoagulation (RCA) is the most promising. By reducing ionized calcium inside the extracorporeal circuit, citrate is able to block the coagulation cascade at different levels. Compared with unfractionated heparin, several studies reported better filter survival times and a marked reduction of transfusion rates with RCA. Despite the positive reports about the efficacy and safety of RCA, the use of this alternative method of anticoagulation appears to be relatively limited. Desirable future improvements in RCA should be focused on simplifying protocols, minimizing the need for calcium and magnesium supplementation, increasing the flexibility of buffer balance, and introducing customized dialysis systems able to deliver automated RCA. In particular, safe protocols with automated delivery of citrate and calcium can allow easy parameter settings that can be adapted to a wide range of clinical situations, facilitating the wider use of RCA in the coming years.
连续性肾脏替代治疗（CRRT）是治疗危重症患者严重急性肾损伤最广泛使用的技术。CRRT需要长期抗凝是其最重要的缺点，而临床上重要的出血会显著增加死亡风险。因此，应更广泛地采用替代抗凝方法。在全身性肝素抗凝的潜在替代方法中，局部枸橼酸抗凝（RCA）最具前景。通过降低体外循环内的离子钙，枸橼酸能够在不同水平阻断凝血级联反应。与普通肝素相比，多项研究报告显示RCA可使滤器使用寿命更长，输血率显著降低。尽管有关于RCA有效性和安全性的积极报道，但这种替代抗凝方法的使用似乎相对有限。RCA未来理想的改进应集中在简化方案、减少钙和镁补充的需求、增加缓冲液平衡的灵活性以及引入能够实现自动化RCA的定制透析系统。特别是，具有枸橼酸和钙自动输注功能的安全方案可以实现易于调整的参数设置，以适应广泛的临床情况，从而在未来几年促进RCA的更广泛应用。
