Division of Critical Care Medicine, Department of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Division of Critical Care Medicine, Department of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
Blood Purif. 2023;52(5):455-463. doi: 10.1159/000529076. Epub 2023 Mar 1.
The use of anticoagulants during continuous renal replacement therapy (CRRT) is essential. Regional citrate anticoagulation (RCA) is recommended rather than systemic heparinization to prolong the filter's lifespan in patients at high risk of bleeding. However, commercial citrate is expensive and may not be available in resource-limited areas. The objective of this study is comparing filter life between our locally made customized RCA and no anticoagulation. The primary outcomes were the first circuit life in hours and the number of filters used within the first 72 h of therapy.
We conducted a single-center prospective randomized controlled trial in critically ill patients requiring CRRT. The participants were randomized to receive continuous venovenous hemofiltration (CVVH) with either customized RCA or no anticoagulant.
Of 76 patients, 38 were randomized to receive customized RCA and 38 to receive CVVH without anticoagulant. There was no significant difference in baseline characteristics between the two groups. Compared to anticoagulant-free group, the median circuit life of customized RCA group was significantly longer [44.9 (20.0, 72.0) vs. 14.3 (7.0, 22.0) hours; p < 0.001]. The number of filters used within 72 h was significant lower [2.0 (1.0, 2.0) vs. 2.5 (1.0, 3.0); p < 0.015]. RCA was prematurely discontinued in 5 patients due to citrate accumulation (2 cases) and severe metabolic acidosis requiring higher dose of CVVH (3 cases). No differences in bleeding complications were observed (p = 0.99).
Customized citrate-based replacement solution improved filter survival in CVVH compared to anticoagulant-free strategy. This regimen is safe, feasible, and suitable for low- to middle-income countries.
在连续肾脏替代治疗（CRRT）期间使用抗凝剂至关重要。建议使用局部枸橼酸抗凝（RCA）而不是全身肝素化，以延长高出血风险患者的滤器寿命。然而，商业枸橼酸盐昂贵，并且在资源有限的地区可能无法获得。本研究旨在比较我们本地定制的 RCA 和无抗凝剂之间的滤器寿命。主要结局是每小时的第一回路寿命和治疗的前 72 小时内使用的滤器数量。
我们在需要 CRRT 的危重症患者中进行了一项单中心前瞻性随机对照试验。参与者被随机分配接受连续静脉-静脉血液滤过（CVVH），分别接受定制 RCA 或无抗凝剂治疗。
在 76 名患者中，38 名被随机分配接受定制 RCA，38 名接受无抗凝剂的 CVVH。两组患者的基线特征无显著差异。与无抗凝剂组相比，定制 RCA 组的中位回路寿命明显更长[44.9（20.0，72.0）vs. 14.3（7.0，22.0）小时；p<0.001]。72 小时内使用的滤器数量明显减少[2.0（1.0，2.0）vs. 2.5（1.0，3.0）；p<0.015]。由于柠檬酸积聚（2 例）和需要更高剂量 CVVH 的严重代谢性酸中毒（3 例），5 例患者提前停止使用 RCA。未观察到出血并发症的差异（p=0.99）。
与无抗凝剂策略相比，基于定制的枸橼酸盐替代溶液可提高 CVVH 中的滤器存活率。这种方案安全、可行，适合中低收入国家。
