持续肾脏替代治疗中的枸橼酸盐抗凝：滤器相关结局的多中心儿科重症监护病房研究

Citrate Anticoagulation in Continuous Renal Replacement Therapy: Multicenter PICU Study of Filter-Related Outcomes.

作者信息

Kihtir Hasan S, Duyu Muhterem, Mementoglu Mehmet E, Tolunay Ilknur, Kendirli Tanil, Ekinci Faruk, Botan Edin, Ongun Ebru A, Asik Ayse, Gun Emrah, Ucmak Hacer, Sevketoglu Esra, Yildizdas Dincer

机构信息

Department of Pediatric Critical Care, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey.

Department of Pediatric Critical Care, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey.

出版信息

Pediatr Crit Care Med. 2025 Feb 1;26(2):e216-e226. doi: 10.1097/PCC.0000000000003661. Epub 2024 Dec 19.

DOI:10.1097/PCC.0000000000003661

PMID:39699267

Abstract

OBJECTIVES

To examine citrate anticoagulation in continuous renal replacement therapy (CRRT) in the PICU.

DESIGN

Post hoc analysis of a curated, multicenter dataset collected from January 1, 2022, to June 1, 2023.

SETTING

Seven PICUs in Turkey.

PATIENTS

PICU admissions in need of CRRT, 28 days to 18 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In 128 filters used in 73 patients, the effective filter life (EFL) restricted to 72 hours was a median (interquartile range [IQR]) of 40.5 hours (IQR, 21-58 hr); total EFL was a median of 59 hours (IQR, 28-89 hr). Analysis of the receiver operating characteristic curve for initial citrate infusion dose (CID) and whether EFL reached 72 hours identified a cutoff level for initial CID of greater than 2.64 mmol citrate per liter of patient blood flow (mmol/L-bf). As expected, the two filter groups categorized by initial CID (≥ 2.7 vs. < 2.7 mmol/L-bf) showed filters in children receiving higher initial dosing had longer total EFL (72 hr [IQR, 48-104 hr] vs. 38.5 hr [IQR, 18-84 hr]; p = 0.03). We failed to identify an association between CRRT for over 24 or 48 hours and greater odds (odds ratio [OR], 95% CI) of citrate accumulation (OR, 2.23; 95% CI, 0.82-6.13; p = 0.118 or OR, 1.78; 95% CI, 0.84-3.8; p = 0.134, respectively). However, we cannot exclude up to 6.1- or 3.8-fold odds of citrate accumulation; of note, CRRT over 72 hours was associated with greater odds of citrate accumulation (OR, 2.17; 95% CI, 1.01-4.68; p = 0.04). Citrate lock syndrome occurred in eight of 128 (6.3%; 95% CI, 3-11.4%) filters, and resolved without termination of CRRT. On multivariable analysis, a higher patient initial lactate concentration was associated with an 18% (95% CI, 7-30%) greater hazard of developing citrate accumulation.

CONCLUSIONS

Citrate anticoagulation for CRRT is an option for children. Choosing an initial CID greater than or equal to 2.7 mmol/L-bf provides longer EFL but with the associated potential of citrate accumulation. Further studies are needed on initial CID and duration of EFL.

摘要

目的

研究儿科重症监护病房（PICU）中连续性肾脏替代治疗（CRRT）的枸橼酸盐抗凝效果。

设计

对2022年1月1日至2023年6月1日收集的经整理的多中心数据集进行事后分析。

地点

土耳其的7个PICU。

患者

需要进行CRRT的PICU住院患者，年龄在28天至18岁之间。

干预措施

无。

测量指标及主要结果

在73名患者使用的128个滤器中，限制在72小时的有效滤器寿命（EFL）中位数（四分位间距[IQR]）为40.5小时（IQR，21 - 58小时）；总EFL中位数为59小时（IQR，28 - 89小时）。对初始枸橼酸盐输注剂量（CID）以及EFL是否达到72小时的受试者工作特征曲线分析确定，初始CID的临界水平为每升患者血流量大于2.64 mmol枸橼酸盐（mmol/L-bf）。正如预期的那样，按初始CID分类的两个滤器组（≥2.7 vs. <2.7 mmol/L-bf）显示，接受较高初始剂量的儿童使用的滤器总EFL更长（72小时[IQR，48 - 104小时] vs. 38.5小时[IQR，18 - 84小时]；p = 0.03）。我们未能确定超过24或48小时的CRRT与枸橼酸盐蓄积的更高几率（优势比[OR]，95%可信区间）之间存在关联（OR，2.23；95%可信区间，0.82 - 6.13；p = 0.118或OR，1.78；95%可信区间，0.84 - 3.8；p = 0.134）。然而，我们不能排除枸橼酸盐蓄积几率高达6.1倍或3.8倍的情况；值得注意的是，超过72小时的CRRT与枸橼酸盐蓄积的更高几率相关（OR，2.17；95%可信区间，1.01 - 4.68；p = 0.04）。128个滤器中有8个（6.3%；95%可信区间，3 - 11.4%）发生了枸橼酸盐封管综合征，且在未终止CRRT的情况下得到解决。多变量分析显示，患者初始乳酸浓度较高与发生枸橼酸盐蓄积的风险增加18%（95%可信区间，7 - 30%）相关。