Dyla Agnieszka, Mielnicki Wojciech, Bartczak Joanna, Zawada Tomasz, Garba Piotr
Anesthesiology 4th Military Clinical Hospital, Wroclaw, Poland.
Artif Organs. 2017 Sep;41(9):818-826. doi: 10.1111/aor.12876. Epub 2017 Mar 23.
Liver failure is a serious and often deadly disease often requiring MARS (Molecular Adsorbent Recirculating System) therapy. Choosing the safe and effective method of anticoagulation during artificial liver support systems seems to be very difficult and extremely important. The aim of this study was to assess effectiveness and safety of regional anticoagulation with citrate in liver failure patients during MARS. We used a single center observational study. We analyzed 158 MARS sessions performed in 65 patients: 105 (66.5%) sessions in 41 patients with heparin anticoagulation, 40 (25.3%) sessions in 19 patients with citrate, and 13 (8%) sessions in only five patients without anticoagulation, that were excluded from part of the analysis. To determine the effectiveness of regional anticoagulation with citrate, probability of filter survival and changes in laboratory parameters were analyzed according to the applied method of anticoagulation. The safety of citrate was determined by Ca/Ca ratio, acid-base balance, bleeding complications, and the need for blood product transfusions. The probability of filter survival in the citrate group was 94% and in the heparin group 82% (P = 0.204). There was no relationship between the method of anticoagulation and effectiveness of MARS therapy in lowering the levels of the analyzed parameters. Only one patient had a Ca/Ca ratio higher than he safety margin. There were no statistically significant changes in pH and lactate level irrespective of anticoagulation; bicarbonate dropped significantly only in the heparin group (P = 0.03). The frequency of bleeding complications and the need for transfusions did not differ significantly between groups. Regional anticoagulation with citrate can be an effective and safe method of anticoagulation during MARS therapy, but requires attentive monitoring and further studies in liver failure patients.
肝衰竭是一种严重且常常致命的疾病，通常需要进行分子吸附循环系统（MARS）治疗。在人工肝支持系统中选择安全有效的抗凝方法似乎非常困难但极其重要。本研究的目的是评估在MARS治疗期间，采用柠檬酸盐进行局部抗凝在肝衰竭患者中的有效性和安全性。我们采用了单中心观察性研究。我们分析了65例患者进行的158次MARS治疗：41例采用肝素抗凝的患者进行了105次（66.5%）治疗，19例采用柠檬酸盐抗凝的患者进行了40次（25.3%）治疗，仅5例未进行抗凝的患者进行了13次（8%）治疗，这5例患者被排除在部分分析之外。为了确定柠檬酸盐局部抗凝的有效性，根据应用的抗凝方法分析了滤器存活的概率和实验室参数的变化。通过钙/总钙比值、酸碱平衡、出血并发症以及输血需求来确定柠檬酸盐的安全性。柠檬酸盐组滤器存活的概率为94%，肝素组为82%（P = 0.204）。抗凝方法与MARS治疗降低分析参数水平的有效性之间没有关联。只有1例患者的钙/总钙比值高于安全界限。无论抗凝情况如何，pH值和乳酸水平均无统计学显著变化；仅肝素组的碳酸氢盐显著下降（P = 0.03）。各组之间出血并发症的发生率和输血需求没有显著差异。在MARS治疗期间，采用柠檬酸盐进行局部抗凝可能是一种有效且安全的抗凝方法，但在肝衰竭患者中需要密切监测并进一步研究。
