抗凝治疗在连续性肾脏替代治疗中的应用与 90 天结局的相关性：一项多中心研究。

Association of anticoagulation use during continuous kidney replacement therapy and 90-day outcomes: A multicentre study.

机构信息

Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore.

Department of Respiratory Service, Department of Medicine, Woodlands Health Campus, Singapore.

出版信息

Ann Acad Med Singap. 2023 Aug 30;52(8):390-397. doi: 10.47102/annals-acadmedsg.202337.

DOI:10.47102/annals-acadmedsg.202337

PMID:38920170

Abstract

INTRODUCTION

Anticoagulation is recommended during continuous kidney replacement therapy (CKRT) to prolong the filter lifespan for optimal filter performance. We aimed to evaluate the effect of anticoagulation during CKRT on dialysis dependence and mortality within 90 days of intensive care unit (ICU) admission.

METHOD

Our retrospective observational study evaluated the first CKRT session in critically ill adults with acute kidney injury (AKI) in Singapore from April to September 2017. The primary outcome was a composite of dialysis dependence or death within 90 days of ICU admission; the main exposure variable was anticoagulation use (regional citrate anticoagulation [RCA] or systemic heparin). Multivariable logistic regression was performed to adjust for possible confounders: age, female sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, liver dysfunction, coagulopathy (international normalised ratio[INR] >1.5) and platelet counts of less than 100,000/uL).

RESULTS

The study cohort included 276 patients from 14 participating adult ICUs, of whom 176 (63.8%) experienced dialysis dependence or death within 90 days of ICU admission (19 dialysis dependence, 157 death). Anticoagulation significantly reduced the odds of the primary outcome (adjusted odds ratio [AOR] 0.47, 95% confidence interval [CI] 0.27-0.83, P=0.009). Logistic regression analysis using anticoagulation as a 3-level indicator variable demonstrated that RCA was associated with mortality reduction (AOR 0.46, 95% CI 0.25-0.83, P=0.011), with heparin having a consistent trend (AOR 0.51, 95% CI 0.23-1.14, P=0.102).

CONCLUSION

Among critically ill patients with AKI, anticoagulation use during CKRT was associated with reduced dialysis or death at 90 days post-ICU admission, which was statistically significant for regional citrate anticoagulation and trended in the same direction of benefit for systemic heparin anticoagulation. Anticoagulation during CKRT should be considered whenever possible.

摘要

简介

在连续肾脏替代治疗（CKRT）期间建议抗凝，以延长过滤器的使用寿命，从而实现最佳的过滤器性能。我们旨在评估 ICU 入院后 90 天内 CKRT 期间抗凝对透析依赖和死亡率的影响。

方法

我们的回顾性观察性研究评估了 2017 年 4 月至 9 月期间新加坡重症监护病房中急性肾损伤（AKI）的危重成人的首次 CKRT 治疗。主要结局为 ICU 入院后 90 天内透析依赖或死亡的复合结局；主要暴露变量是抗凝使用（局部枸橼酸盐抗凝[RCA]或全身肝素）。采用多变量逻辑回归调整可能的混杂因素：年龄、女性、急性生理学和慢性健康评估（APACHE II）评分、肝功能障碍、凝血障碍（国际标准化比值[INR]＞1.5）和血小板计数＜100，000/uL）。

结果

研究队列包括来自 14 家参与成人 ICU 的 276 名患者，其中 176 名（63.8%）在 ICU 入院后 90 天内经历了透析依赖或死亡（19 名透析依赖，157 名死亡）。抗凝显著降低了主要结局的可能性（调整后的优势比[OR]0.47，95%置信区间[CI]0.27-0.83，P=0.009）。使用抗凝作为 3 级指示变量的逻辑回归分析表明，RCA 与死亡率降低相关（OR 0.46，95%CI 0.25-0.83，P=0.011），肝素具有一致的趋势（OR 0.51，95%CI 0.23-1.14，P=0.102）。