枸橼酸-葡萄糖抗凝溶液在高危出血患者实施连续性肾脏替代治疗中的应用

ACD- A solution as anticoagulant during continuous renal replacement therapy in high risk bleeding patients

目的探讨枸橼酸-葡萄糖抗凝溶液（ACD—A）在高危出血患者实施连续性肾脏替代治疗（CRRT）中的有效性和安全性。方法选择40例行CRRT治疗的高危出血患者，随机分为ACD—A组（22例，行CRRT61例次）和无肝素组（18例，行CRRT47例次）。治疗模式为连续性静脉．静脉血液滤过（CVVH）。监测治疗前后血肌酐、凝血功能、电解质、酸碱指标变化。记录患者生命体征、血滤器凝血情况及临床出血事件。结果（1）两组患者治疗后血肌酐均显著下降，ACD—A组下降率明显高于无肝素组[（55．4±10．2）％比（42．0±5．2）％，P=0．031]。（2）ACD．A组平均治疗时间为（17．3±3．8）h，无肝素组为（9．7±4．5）h，两组比较差异有统计学意义（P=0．019）。ACD—A组滤器Ⅱ级以上凝血发生率明显少于无肝素组（4．9％比88％，P〈0．001）。（3）与治疗前相比，两组患者治疗后凝血功能均无明显变化（均P〉0．05）。（4）ACD—A组治疗过程中血清电解质、酸碱指标及血糖均趋于稳定。（5）两组患者治疗过程中生命体征稳定，均无出血事件发生。结论ACD—A应用于高危出血病人的CRRT抗凝治疗安全、有效、方便。通过配置适宜的置换液和严密的实验室监测，可防止代谢紊乱的发生。

Objective To assess the efficacy and safety of ACD-A solution as anticoagulant during continuous renal replacement therapy （CRRT） in high risk of bleeding patients. Methods Forty high risk bleeding patients on continuous venovenous hemofihration （CVVH） were randomly divided into two groups： ACD-A group （22 patients, 61 cases） and heparin-free group （18 patients, 47 cases）. Serum ereatinine, function of the coagulation system, electrolyte and acid-base were monitored pre- and post- CVVH. The vital signs of the patients during treatment, dialyser clotting and the incidence of bleeding episodes were recorded. Results （1） The serum level of creatinine decreased significantly after treatment in both groups, but the rate of decrease was obviously higher in ACD- A group than that in heparinfree group[（55.4±10.2）% vs （42.0±5.2）%, P = 0.031]. （2） The average duration of CVVH treatment was （17.3±3.8） h in ACD-A group and （9.7±4.5） h in heparin-free group. There was significant difference between them （P = 0.019）. The frequency of dialyzer clotting was much higher in heparin-free group than that in ACD-A group （88% vs 4.9%, P 〈 0.001）. （3） There was no significant difference in the function of the coagulation system between pre- and post-CVVH in either group （P 〉 0.05）. （4） Electrolyte, acid-base and glucose tended to be stable during the treatment in ACD -A group. （5） The vital signs were kept stable and no bleeding episodes were found in all patients of two groups. Conclusions Anticoagulation with ACD- A is safe, effective and convenient for CRRT in critically ill patients at high risk of bleeding. The occurrence of complications can be reduced by configurating appropriate replacement fluid and close laboratory monitoring.