Acute and Chronic Renal Failure Unit,, †1 ICU,, ‡2 ICU,, §Heart Surgery ICU, and, *Kidney-Pancreas Transplant Unit, Parma University Hospital, Parma, Italy;, ‖Nephrology and Transplantation Unit, Bary University Hospital, Bari, Italy;, ¶Nephrology and Dialysis Unit, Rome University Hospital, Roma, Italy.
Clin J Am Soc Nephrol. 2013 Oct;8(10):1670-8. doi: 10.2215/CJN.00510113. Epub 2013 Aug 29.
A simple anticoagulation protocol was developed for sustained low-efficiency dialysis (SLED) in patients with AKI, based on the use of anticoagulant citrate dextrose solution formulation A (ACD-A) and standard dialysis equipment. Patients' blood recalcification was obtained from calcium backtransport from dialysis fluid.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All patients treated with SLED (8- to 12-hour sessions) for AKI in four intensive care units of a university hospital were studied over a 30-month period, from May 1, 2008 to September 30, 2010. SLED interruptions and their causes, hemorrhagic complications, as well as coagulation parameters, ionized calcium, and blood citrate levels were recorded.
This study examined 807 SLED sessions in 116 patients (mean age of 69.7 years [SD 12.1]; mean Acute Physiology and Chronic Health Evaluation II score of 23.8 [4.6]). Major bleeding was observed in six patients (5.2% or 0.4 episodes/100 person-days follow-up while patients were on SLED treatment). Citrate accumulation never occurred, even in patients with liver dysfunction. Intravenous calcium for ionized hypocalcemia (< 3.6 mg/dl or < 0.9 mmol/L) was needed in 28 sessions (3.4%); in 8 of these 28 sessions (28.6%), low ionized calcium was already present before SLED start. In 92.6% of treatments, SLED was completed within the scheduled time (median 8 hours). Interruptions of SLED by impending/irreversible clotting were recorded in 19 sessions (2.4%). Blood return was complete in 98% of the cases. In-hospital mortality was 45 of 116 patients (38.8%).
This study protocol affords efficacious and safe anticoagulation of the SLED circuit, avoiding citrate accumulation and, in most patients, systematic calcium supplementation; it can be implemented with commercial citrate solutions, standard dialysis equipment, on-line produced dialysis fluid, and minimal laboratory monitoring.
我们为急性肾损伤（AKI）患者的持续性低效率透析（SLED）制定了一个简单的抗凝方案，基于使用抗凝剂柠檬酸钠葡萄糖溶液配方 A（ACD-A）和标准透析设备。患者血液的重新钙化是通过透析液中的钙反向转运获得的。
设计、地点、参与者和测量：2008 年 5 月 1 日至 2010 年 9 月 30 日期间，在一家大学医院的四个重症监护病房中，对接受 AKI 治疗的 116 名患者（8-12 小时）进行了为期 30 个月的 SLED 研究。记录了 SLED 中断及其原因、出血并发症以及凝血参数、离子钙和血液柠檬酸盐水平。
本研究共检查了 116 名患者的 807 次 SLED 治疗（平均年龄 69.7 岁[12.1 岁]；平均急性生理学和慢性健康评估 II 评分 23.8[4.6]）。6 名患者（5.2%或 0.4 例/100 人-天）出现大出血。即使在肝功能障碍的患者中，也从未发生过柠檬酸盐蓄积。28 次（3.4%）因离子钙缺乏（<3.6mg/dl 或 <0.9mmol/L）需要静脉注射钙；在这 28 次中的 8 次（28.6%），在开始 SLED 前，离子钙就已经降低。在 92.6%的治疗中，SLED 按时完成（中位数 8 小时）。19 次（2.4%）因即将发生/不可逆转的凝血而中断 SLED。98%的情况下血液回流完全。116 名患者中有 45 名（38.8%）住院死亡。
本研究方案为 SLED 回路提供了有效和安全的抗凝作用，避免了柠檬酸盐蓄积，并在大多数患者中避免了系统补钙；它可以使用商业柠檬酸盐溶液、标准透析设备、在线生产的透析液和最小的实验室监测来实施。
