Lim Eng Kuang, Seow Ying-Ying T, Chen Shun E, Yang Gao, Liaw Min Er, Isaac Shimi
Division of Renal Medicine, Khoo Teck Puat Hospital, Singapore, 768828, Singapore.
BMC Nephrol. 2018 Jan 19;19(1):16. doi: 10.1186/s12882-018-0811-y.
For patients unable to receive heparin anticoagulation during haemodialysis, saline flushes to reduce circuit clotting are often the norm. Regional citrate anticoagulation (RCA) although effective is not used by many centres including in Singapore. We wanted to demonstrate the superiority and safety of a simple regional citrate anticoagulation regime, compared to saline flushes, for heparin-free low flux haemodialysis.
This is a prospective, open label, cross over study on 25 sequential haemodialysis sessions for inpatients receiving heparin-free haemodialysis. Patients were allocated either to regional citrate anticoagulation or standard heparin free haemodialysis and subsequently cross over to the alternate method. RCA was carried out using a protocol derived from previous studies. Assessment of anticoagulation was performed using visual inspection of clot formation in dialysis circuits and post-filter ionized calcium (iCa2+) using point-of-care Ionized calcium device at stipulated intervals. Intravenous Calcium gluconate replacement was given to patients receiving citrate adjusting the rate according to pre-filter iCa2+. Laboratory analyses of electrolytes were also assessed at the start and end of the RCA sessions.
There were no clots in the RCA arm, with 79% (n = 19) in the saline flush arm having some clot, including 1 clotted circuit. Post-filter iCa2+ at various time points were within acceptable range. Electrolyte readings in the RCA group were all within normal limits except for 4 cases of total Calcium:iCa2+ ratio > 2.5.
RCA is confirmed to be superior to saline flushes for circuit patency. We have a simple and safe protocol that can be followed for low flux haemodialysis. The study was approved by Singapore National Health Group domain-specific ethnical committee. NHG DSRB reference number 2014/01037.
Trial registration number: ISRCTN69952745 (registration date 8/11/17).
对于在血液透析期间无法接受肝素抗凝治疗的患者，通常会用生理盐水冲洗以减少体外循环凝血。尽管局部枸橼酸抗凝（RCA）有效，但包括新加坡在内的许多中心并未采用。我们旨在证明一种简单的局部枸橼酸抗凝方案相较于生理盐水冲洗，在无肝素低通量血液透析中的优越性和安全性。
这是一项针对25次连续住院患者无肝素血液透析治疗的前瞻性、开放标签、交叉研究。患者被随机分配至局部枸橼酸抗凝组或标准无肝素血液透析组，随后交叉至另一种方法。RCA采用源自既往研究的方案进行。通过目视检查透析回路中的血栓形成情况，并使用即时检测离子钙设备在规定间隔时间测定滤器后离子钙（iCa2+）水平，以评估抗凝效果。根据滤器前iCa2+水平，对接受枸橼酸治疗的患者给予静脉葡萄糖酸钙补充，并调整给药速率。在RCA治疗开始和结束时，还对电解质进行了实验室分析。
RCA组未出现血栓，生理盐水冲洗组有79%（n = 19）出现了一些血栓，包括1个回路完全堵塞。各时间点的滤器后iCa2+均在可接受范围内。RCA组的电解质读数除4例总钙：iCa2+比值>2.5外，均在正常范围内。
RCA在保持体外循环通畅方面优于生理盐水冲洗。我们有一个简单且安全的方案可用于低通量血液透析。该研究已获得新加坡国家卫生集团特定领域伦理委员会的批准。NHG DSRB参考编号2014/01037。
试验注册号：ISRCTN699X2745（注册日期：2017年11月8日）。
