枸橼酸抗凝在持续缓慢低效血液透析中的疗效和安全性

The safety and efficacy of regional citrate anticoagulation in sustained low efficiency dialysis

目的观察枸橼酸抗凝应用于持续缓慢低效血液透析（SLED）的安全性及有效性。方法前瞻性观察四川大学华西医院2011年8月至2012年9月收治的45例急性肾损伤或终末期肾病患者。所有患者血管通路均采用颈／股静脉留置双腔导管，采用费森尤斯4008sARrTplus透析机进行SLED，治疗时间为8h。4％枸橼酸钠以130ml／h由动脉端泵人，血流量150ml／min，无钙透析液流量200ml／min，10％葡萄糖酸钙以40ml／h静脉端泵入。分别在0、2、5h测定枸橼酸浓度，并观察外周血及透析器后血清游离钙水平。结果45例患者行SLED治疗162例次，除2例次患者分别在治疗4h及6h时出现1次透析器Ⅲ。凝血需更换透析管路外，余160例次（98．8％）SLED均顺利完成。0h枸橼酸浓度为（0．14±0．06）mmol／L，虽然2h及5h外周血枸橼酸浓度轻度升高，但两组间差异无明显统计学意义[（1．08±0．12）mmo/L比（1．11±0．17）mmoL／L，P〉0．05]。0、2、5h的外周血游离钙水平分别为（1．04±0．13）mmo/L、（1．074-0．23）mmo/L及（1．04±0．24）mmol／L，组间差异无统计学意义（P〉0．05）。2h及5h滤器后游离钙水平分别为（0．31±0．04）mmo/L及（0．29±0．03）mmo/L。2h和5h的跨膜压分别为（104．54±17．8）mmHg（1mmHg=0．133kPa）和（109．3±20．1）mm Hg，两组间差异无统计学意义（P〉0．05）。5h测定外周血凝血酶原时间及活化部分凝血活酶时间与治疗前比较差异无统计学意义（P〉0．05）。在SLED治疗过程中未出现出血、血小板减少、心律失常、高钠血症、代谢性碱中毒及低血压事件。结论枸橼酸抗凝在SLED应用中安全有效，在保证有效的局部抗凝过程下不影响体内的凝血功能，为临床医生提供了一种新型的SLED抗凝方式。

Objective To evaluate the safety and efficacy of regional citrate anticoagulation in sustained low efficiency dialysis （SLED）. Methods A total of 45 patients with acute kidney injury （AKI） or end stage renal disease （ESRD） admitted in our hospital from August 2011 to September 2012 were prospectively enrolled in this study. All the patients received SLED treatment by Fresenius 4008sARrTplus dialyzer through either femoral or internal jugular venous catheter, with each session of SLED treatment lasting for 8 hours. All the patients were pumped in 4% tri-sodium citrate solution through the arterial line at 130 ml/hour and 10% calcium gluconate through the venous line at 40 ml/hour. The blood flow was 150 mL/minute while the calcium-free dialysate was delivered at 200 ml/minute. Systemic citrate concentration, peripheral and post dialyzer ionized calcium levels at 0, 2 and 5 hour were recorded. Results All the 45 patients underwent 162 sessions of SLED with 2 were discontinued due to Ⅲ° dialyzer coagulation, and other 160 SLED sessions （98.8%） were all successfully performed. The systemic citrate concentration at 0 hour was （0. 14 ± 0. 06） mmol/L, the systemic citrate concentrations at 2 and 5 hour were sightly increased while no statistical difference was found[ （1.08 ± 0. 12）mmol/L vs （1.11 ± 0. 17） mmol/L, P 〉 0. 05 ]. The 0, 2, 5 hour peripheral blood ionized calcium levels were （ 1.04 ± 0. 13 ） mmol/L, （ 1.07 ± 0. 23 ） mmol/L and （ 1.04 ± 0. 24 ） mmol/L, respectively, with no significant difference （ P 〉 0. 05 ）. The post dialyzer ionized calcium levels were （0. 31±0. 04） mmol/L at 2 hour and （0. 29±0. 03） mmol/L at 5 hour. The transmembrane pressure at 2 hour was （ 104. 5 ± 17.8） mm Hg（ 1 mm Hg = 0. 133 kPa） , and （ 109. 3 ± 20. 1 ） mm Hg at 5 hour, however the increase was not of statistical significance （ P 〉 0.05 ）. At 5 hour, prothrombin time and activated partial thrombin time were identified to be similar to those before SLED. During the treatments, no bleeding complication, thrombocytopenia, cardiac arrhythmia, hypernatremia, metabolic alkalosis or hypotension was observed. Conclusion SLED under regional citrate anticoagulation is safe and effective. Citrate achieves satisfying regional anticoagulation effect without interfering systemic clotting function, thus this study provides a new option of SLED anticoagulation for clinicians.