连续性肾脏替代治疗期间的标准化局部枸橼酸抗凝：单中心经验

Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience.

作者信息

Pachisia Anant V, Kumar G Praveen, Harne Rahul, Jagadeesh K N, Patel Sweta J, Pal Divya, Tyagi Pooja, Pattajoshi Swagat, Brar Keerti, Patel Parimal B, Zatakiya Ronak, Chandra Subhash, Govil Deepak

机构信息

Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India.

Department of Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

出版信息

Indian J Crit Care Med. 2024 Sep;28(9):859-865. doi: 10.5005/jp-journals-10071-24797. Epub 2024 Aug 31.

DOI:10.5005/jp-journals-10071-24797

PMID:39360210

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11443258/

Abstract

BACKGROUND

Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature.

OBJECTIVE

The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life.

METHODOLOGY

It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA.

RESULTS

A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) ( ≤ 0.001) and those who were post-living donor liver transplant recipients ( = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation.

CONCLUSION

Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients.

HOW TO CITE THIS ARTICLE

Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, . Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.

摘要

背景

局部枸橼酸抗凝（RCA）已成为一种可降低出血风险和滤器凝血的治疗方式。基于使用RCA进行连续性肾脏替代治疗（CRRT）的初步经验，我们根据已发表的文献制定了一份工作方案。

目的

本研究旨在评估在需要抗凝的CRRT过程中常规使用RCA的方案以及滤器使用寿命。

方法

这是一项于2022年9月至2023年7月在一家三级护理医院进行的单中心、开放标签、前瞻性、非随机、非干预、单臂观察性研究。所有患有急性肾损伤（AKI）或高氨血症且需要CRRT并必须使用抗凝剂的成年患者均纳入本研究。在持续静静脉血液透析滤过（CVVHDF）期间，研究在百特（Baxter）Prisma Flex CRRT机器上使用Prisma Flex M100 AN 69透析器。所有研究患者的目标CRRT剂量为25 - 30 mL/kg/小时。基于已发表的文献，我们制定了一份使用RCA管理CRRT患者的工作方案（附录1）。

结果

本研究共分析了159例患者。使用RCA时滤器的中位[四分位间距（IQR）]使用寿命为30（12 - 55）小时。33.3%的患者观察到滤器凝血。52.25%的患者存在枸橼酸蓄积，但按照方案中的纠正措施处理后，枸橼酸蓄积得到缓解，没有患者停止CRRT治疗。没有患者出现枸橼酸中毒。慢性肝病（CLD）患者（≤0.001）和活体供肝移植受者（ = 0.004）的枸橼酸蓄积在统计学上有显著增加。此外，基线时（CRRT开始后6小时）乳酸水平较高的患者，枸橼酸蓄积的可能性更高。