The Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China.
Department of Health Statistics, the Fourth Military Medical University, Xi'an, China.
Clin J Am Soc Nephrol. 2024 Feb 1;19(2):151-160. doi: 10.2215/CJN.0000000000000351. Epub 2023 Nov 6.
The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients.
Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure.
Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca 2+tot /Ca 2+ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca 2+tot /Ca 2+ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours.
For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca 2+tot /Ca 2+ion >2.5.
RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190 .
对于出血风险较高的严重肝衰竭患者，连续肾脏替代治疗（CKRT）中无抗凝与局部枸橼酸盐抗凝的疗效和安全性意见不一。我们进行了一项随机对照试验，以评估这些患者中 CKRT 时无抗凝与局部枸橼酸盐抗凝的效果。
我们考虑将出血风险较高的肝衰竭成人患者纳入研究。纳入的参与者被随机分配接受局部枸橼酸盐抗凝或无抗凝 CKRT。主要终点是滤器衰竭。
在纳入的参与者中，44 人和 45 人分别被随机分配接受局部枸橼酸盐抗凝和无抗凝 CKRT。无抗凝组的滤器衰竭发生率明显更高（25 [56%] 例与 12 [27%] 例，P = 0.003），这一结果通过累积发生率函数分析和仅包括第一次 CKRT 时的敏感分析得到了证实。在累积发生率函数分析中，无抗凝和局部枸橼酸盐抗凝组在 24、48 和 72 小时的累积滤器衰竭率分别为 31%、58%和 76%和 11%、23%和 35%。局部枸橼酸盐抗凝组的 Ca 2+tot /Ca 2+离子>2.5 的发生率明显更高（7%与 57%，P < 0.001）、低钙血症（51%与 82%，P = 0.002）和严重低钙血症（13%与 77%，P < 0.001）。然而，大多数（73%）Ca 2+tot /Ca 2+离子比升高在钙替代率上调后恢复正常。在局部枸橼酸盐抗凝组中，6 小时后，系统枸橼酸盐浓度没有明显增加。
对于需要 CKRT 的出血风险较高的肝衰竭患者，局部枸橼酸盐抗凝可显著延长滤器寿命，但肝衰竭患者局部枸橼酸盐抗凝与低钙血症、严重低钙血症和 Ca 2+tot /Ca 2+离子>2.5 的风险显著增加相关。
RCA for CRRT in Liver Failure and High Risk Bleeding Patients，NCT03791190。
