Wen Ming, Küchle Claudius, Steubl Dominik, Satanovskji Robin, Heemann Uwe, Suttmann Yana, Angermann Susanne, Kemmner Stephan, Rehbehn Lisa, Huber Monika, Hauser Christine, Schmaderer Christoph, Reichelt Anna-Lena, Haller Bernhard, Renders Lutz
Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
Institute of Medical Statistics and Epidemiology, Technische Universität München, Munich, Germany.
BMC Nephrol. 2018 Apr 3;19(1):79. doi: 10.1186/s12882-018-0879-4.
The high cost, complexity of the available protocols, and metabolic complications are the major barriers that impede the clinical utilization of regional citrate anticoagulation (RCA) for sustained low efficiency dialysis (SLED) in critically ill patients. By comparing a novel protocol for SLED using 30% citrate solution with common protocol using unfractionated heparin, this study aimed to provide new insights for clinical applications of RCA.
In this retrospective study, a total of 282 critically ill patients who underwent SLED with citrate and/or heparin anticoagulation in six adult ICUs were enrolled. These patients were divided into three groups based on the anticoagulation regimens they had received during the treatment in ICU: Group 1 (Citrate) had only received treatment with citrate anticoagulation (n=75); Group 2 (Heparin) only with heparin anticoagulation (n=79); and Group 3 (Both) with both citrate and heparin anticoagulation (n=128). We compared the mortality, metabolic complications as well as cost among these groups using different anticoagulation regimens.
The in-hospital mortality did not significantly differ among groups (p> 0.1). However, three patients in heparin group suffered from severe bleeding which led to death, while none in citrate group. Overall, 976 SLED sessions with heparin anticoagulation and 808 with citrate were analyzed. The incidence of extracorporeal circuit clotting was significantly less in citrate (5%), as compared to that in heparin (10%) (p< 0.001). Metabolic complications and hypotension which led to interruption of SLED occurred more frequently, though not significantly, in citrate (p= 0.06, p= 0.23). Furthermore, with 30% citrate solution, the cost of anticoagulant was reduced by 70% in comparison to previously reported protocol using Acid Citrate Dextrose solution A (ACD-A).
Our results indicated that anticoagulation regimens for SLED did not significantly affect the mortality of patients. Citrate anticoagulation was superior to heparin in preventing severe bleeding and circuit clotting. The protocol adopted in this study using 30% citrate solution was safe as well as efficacious. In the meantime, it was much more cost-efficient than other citrate-based protocol.
高成本、现有方案的复杂性以及代谢并发症是阻碍在重症患者中应用局部枸橼酸抗凝（RCA）进行持续低效透析（SLED）的主要障碍。通过比较使用30%枸橼酸溶液进行SLED的新方案与使用普通肝素的方案，本研究旨在为RCA的临床应用提供新见解。
在这项回顾性研究中，纳入了在六个成人重症监护病房接受枸橼酸和/或肝素抗凝的SLED治疗的282例重症患者。根据他们在重症监护病房治疗期间接受的抗凝方案，将这些患者分为三组：第1组（枸橼酸组）仅接受枸橼酸抗凝治疗（n = 75）；第2组（肝素组）仅接受肝素抗凝治疗（n = 79）；第3组（联合组）接受枸橼酸和肝素抗凝治疗（n = 128）。我们比较了这些组使用不同抗凝方案时的死亡率、代谢并发症以及成本。
各组间住院死亡率无显著差异（p > 0.1）。然而，肝素组有3例患者因严重出血导致死亡，而枸橼酸组无。总体而言，分析了976次使用肝素抗凝的SLED治疗和808次使用枸橼酸抗凝的SLED治疗。与肝素组（10%）相比，枸橼酸组体外循环凝血发生率显著更低（5%）（p < 0.001）。枸橼酸组导致SLED中断的代谢并发症和低血压发生频率更高，但无显著差异（p = 0.06，p = 0.23）。此外，与先前报道的使用枸橼酸葡萄糖溶液A（ACD - A）的方案相比，使用30%枸橼酸溶液时，抗凝剂成本降低了70%。
我们的结果表明，SLED的抗凝方案对患者死亡率无显著影响。枸橼酸抗凝在预防严重出血和体外循环凝血方面优于肝素。本研究采用的使用30%枸橼酸溶液的方案安全且有效。同时，它比其他基于枸橼酸的方案更具成本效益。
