以预防 KRT 相关低磷血症为重点，优化酸碱平衡的 CVVH、CVVHDF 和 SLED 的简化区域性柠檬酸盐抗凝方案。
Simplified regional citrate anticoagulation protocol for CVVH, CVVHDF and SLED focused on the prevention of KRT-related hypophosphatemia while optimizing acid-base balance.
机构信息
UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università̀ di Parma, Parma, Italy.
Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy.
出版信息
Nephrol Dial Transplant. 2023 Sep 29;38(10):2298-2309. doi: 10.1093/ndt/gfad068.
BACKGROUND
Hypophosphatemia is a common electrolyte disorder in critically ill patients undergoing prolonged kidney replacement therapy (KRT). We evaluated the efficacy and safety of a simplified regional citrate anticoagulation (RCA) protocol for continuous venovenous hemofiltration (CVVH), continuous venovenous hemodiafiltration (CVVHDF) and sustained low-efficiency dialysis filtration (SLED-f). We aimed at preventing KRT-related hypophosphatemia while optimizing acid-base equilibrium.
METHODS
KRT was performed by the Prismax system (Baxter) and polyacrylonitrile AN69 filters (ST 150, 1.5 m2, Baxter), combining a 18 mmol/L pre-dilution citrate solution (Regiocit 18/0, Baxter) with a phosphate-containing solution (HPO42- 1.0 mmol/L, HCO3- 22.0 mmol/L; Biphozyl, Baxter). When needed, phosphate loss was replaced with sodium glycerophosphate pentahydrate (Glycophos™ 20 mmol/20 mL, Fresenius Kabi Norge AS, Halden, Norway). Serum citrate measurements were scheduled during each treatment. We analyzed data from three consecutive daily 8-h SLED-f sessions, as well as single 72-h CVVH or 72-h CVVHDF sessions. We used analysis of variance (ANOVA) for repeated measures to evaluate differences in variables means (i.e. serum phosphate, citrate). Because some patients received phosphate supplementation, we performed analysis of covariance (ANCOVA) for repeated measures modelling phosphate supplementation as a covariate.
RESULTS
Forty-seven patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) requiring KRT were included [11 CVVH, 11 CVVHDF and 25 SLED-f sessions; mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score 25 ± 7.0]. Interruptions for irreversible filter clotting were negligible. The overall incidence of hypophosphatemia (s-P levels <2.5 mg/dL) was 6.6%, and s-P levels were kept in the normality range irrespective of baseline values and the KRT modality. The acid-base balance was preserved, with no episode of citrate accumulation.
CONCLUSIONS
Our data obtained with a new simplified RCA protocol suggest that it is effective and safe for CVVH, CVVHDF and SLED, allowing to prevent KRT-related hypophosphatemia and maintain the acid-base balance without citrate accumulation.
TRIAL REGISTRATION
NCT03976440 (registered 6 June 2019).
背景
在接受长时间肾脏替代治疗（KRT）的危重症患者中，低磷血症是一种常见的电解质紊乱。我们评估了简化局部枸橼酸抗凝（RCA）方案在连续静脉-静脉血液滤过（CVVH）、连续静脉-静脉血液透析滤过（CVVHDF）和持续低效透析滤过（SLED-f）中的疗效和安全性。我们旨在预防 KRT 相关的低磷血症，同时优化酸碱平衡。
方法
KRT 通过 Prismax 系统（Baxter）和丙烯腈-聚氯乙烯 AN69 过滤器（ST 150，1.5 m2，Baxter）进行，结合 18 mmol/L 预稀释枸橼酸钠溶液（Regiocit 18/0，Baxter）和含磷酸盐溶液（HPO42- 1.0 mmol/L，HCO3- 22.0 mmol/L；Biphozyl，Baxter）。需要时，用磷酸甘油酸钠五水合物（Glycophos™ 20 mmol/20 mL，Fresenius Kabi Norge AS，Halden，挪威）替代磷酸盐丢失。在每次治疗期间安排血清枸橼酸盐测量。我们分析了三个连续的每日 8 小时 SLED-f 疗程以及单个 72 小时 CVVH 或 72 小时 CVVHDF 疗程的数据。我们使用重复测量方差分析（ANOVA）来评估变量均值（即血清磷酸盐、枸橼酸盐）的差异。由于一些患者接受了磷酸盐补充，我们使用重复测量协方差分析（ANCOVA）将磷酸盐补充作为协变量进行建模。
结果
47 例急性肾损伤（AKI）或终末期肾病（ESKD）患者需要 KRT[11 例 CVVH、11 例 CVVHDF 和 25 例 SLED-f 疗程；平均急性生理学和慢性健康评估 II（APACHE II）评分 25 ± 7.0]。不可逆过滤器堵塞的中断可以忽略不计。低磷血症（s-P 水平 <2.5 mg/dL）的总发生率为 6.6%，并且 s-P 水平保持在正常范围内，与基线值和 KRT 方式无关。酸碱平衡得到维持，没有枸橼酸盐蓄积的情况发生。
结论
我们使用新的简化 RCA 方案获得的数据表明，该方案对 CVVH、CVVHDF 和 SLED 有效且安全，可预防 KRT 相关的低磷血症，并维持酸碱平衡，而不会发生枸橼酸盐蓄积。
试验注册
NCT03976440（2019 年 6 月 6 日注册）。
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