长期持续肾脏替代治疗和枸橼酸盐抗凝治疗在危重患者伴肝功能损伤的效果分析

Analysis on the effect of long term continuous renal replacement therapy and citrate anticoagulant therapy in critically ill patients with liver function injury

目的截至目前,对急性肾衰竭的患者仍采用透析的方法。为进行持续性肾脏替代治疗,用枸橼酸盐替代以往的肝素,以减少患者出血的风险。然而有研究表明枸橼酸盐的代谢主要在肝脏进行,本研究拟观测肝病患者在进行持续性肾脏替代治疗时,患者的肝损伤严重程度。方法选自2012年1月至2020年5月,在本院ICU中进行持续性肾脏替代治疗和枸橼酸盐抗凝,且既往有肝功能不全的患者,并排除未行吲哚菁绿血浆清除率测定的患者,本次研究共纳入63位作为研究对象。并在CRRT开始时和过程中均对患者进行肝功、肾功以及其他指标,且分别观测有无枸橼酸盐累积的患者肝损伤情况。结果63位患者CRRT开始和透析过程中,在肌酐、eGFR、胆红素、白蛋白、胆碱酯酶、ICG-PDR和MELD评分未见明显差异(P均>0.05)。考虑到枸橼酸盐主要靠肝脏代谢,对于这些肝功能不全的患者,因此本文对于患者肝功的监测,以评价枸橼酸盐的实际影响。结果表明tCa/iCa比值大于2.4和≤2.4的两组患者中虽然肝功能有不同程度的影响,但是死亡率等指标并无明显差异。结论本次研究表明,枸橼酸盐除在肝脏代谢外,仍存在枸橼酸的肝外代谢的可能,一定程度上避免了危重患者的枸橼酸积累,也证明了枸橼酸盐抗凝的可行性。因此,提高tCa/iCa比率将是疾病严重程度和死亡率的指标,而不是肝脏受损的指标。然而,这些需进一步研究证实。

Objective Up to now,dialysis is still used in patients with acute renal failure.For continuous renal replacement therapy,citrate was used to replace heparin to reduce the risk of bleeding.However,studies have shown that the metabolism of citrate is mainly in the liver.This study aims to observe the severity of liver injury in patients with liver disease undergoing continuous renal replacement therapy.Methods From January 2012 to May 2020,63 patients with liver dysfunction who had received continuous renal replacement therapy and citrate anticoagulation in ICU and had previous liver dysfunction were selected of a hospital were included as subjects.Patients who did not undergo indocyanine green plasma clearance assay were excluded from the study.Liver function,renal function and other indexes were measured at the beginning and during the CRRT,and the liver injury of patients with citrate accumulation was observed.Results There were no significant difference in creatinine,eGFR,bilirubin,albumin,cholinesterase,ICG-PDR and MELD scores in 63 patients at the beginning CRRT and during dialysis(Pall>0.05).Considering that citrate was mainly metabolized by the liver,for these patients with liver dysfunction,this paper monitored the liver function of patients to evaluate the actual effect of citrate.The results showed that although the liver function was affected to different degrees in patients with the ratio of tCa/iCa>2.4 and≤2.4,there was no significant difference in mortality and other indicators between the two groups.Conclusion This study shows that in addition to the metabolism of citrate in the liver,there is still the possibility of extrahepatic metabolism of citric acid,which avoids the accumulation of citrate in critically ill patients to a certain extent,and also proves the feasibility of citrate anticoagulation.Therefore,increasing the ratio of tCa/iCa will be an indicator of disease severity and mortality,rather than an indicator of liver damage.However,these need further research.