局部枸橼酸抗凝在血浆吸附联合血浆置换治疗高危出血倾向肝衰竭患者中的应用

Application of regional citrate anticoagulation during plasma adsorption and plasma exchange for patients with liver failure at high risk of bleeding

目的分析局部枸橼酸抗凝(regional citrate anticoagulation,RCA)在血浆吸附联合血浆置换(plasma adsorption plus plasma exchange,PA+PE)治疗高危出血倾向肝衰竭中的可行性与安全性.方法收集2016-10/2017-07四川大学华西医院感染性疾病中心收治的采用RCA行PA+PE治疗的高危出血倾向肝衰竭患者的临床资料,回顾性分析治疗效果与枸橼酸蓄积、电解质及酸碱变化.当血总钙(Ca tot)与离子钙(Ca ion)的比值(Ca tot/Ca ion)≥2.5时,判定发生了枸橼酸蓄积.结果 7例患者存活2例,死亡5例.共完成24例次R C A的PA+PE治疗.PA治疗期间体外Ca ion浓度为0.28 mmol/L±0.09 mmol/L.45.8%(11/24)例次治疗在PA治疗期间发生了枸橼酸蓄积;至PE治疗末,全部例次治疗均出现了枸橼酸蓄积.治疗后2 h,仍有41.7%(10/24)例次治疗存在枸橼酸蓄积,但已较PE治疗末明显减少(P<0.01);至第2天晨,全部例次治疗均不再存在枸橼酸蓄积.治疗期间及治疗后无新发出血,原有出血未恶化;主要不良反应为碱中毒和一过性低Ca ion血症及高Ca tot血症.结论肝衰竭患者仍具有一定程度的代谢枸橼酸和耐受枸橼酸蓄积的能力.RCA在PA联合PE治疗肝衰竭患者中可能具有一定的可行性及安全性.

AIM To analyze the feasibility and safety of regional citrate anticoagulation （RCA） during plasma adsorption （PA） plus plasma exchange （PE） therapy for patients with liver failure at high risk of bleeding. This was a retrospective study conducted at the Center of Infectious Diseases, West China Hospital of Sichuan University from October 2016 to July 2017. The clinical data of patients with liver failure at high risk of bleeding who received RCA during PA plus PE therapy were collected. The therapeutic effects, citrate accumulation, electrolytes, and acid-base changes were retrospectively analyzed. Citrate accumulation was defined as the total calcium （Catot） to ionized calcium （Caion） ratio （Catot/ Caion）≥ 2.5. Of the seven patients included, two survived and five died. Twenty four sessions of RCA for PA plus PE therapy were accomplished. The mean Caion in vitro during PA therapy was 0.28 mmol/L ＋ 0.09 mmol/L. Citrate accumulation occurred in 45.8% （11/24） of sessions during PA therapy and in all the sessions at the end of PE therapy. Although citrate accumulation still occurred in 41.7% （10/24） of sessions 2 h after PE therapy, it had been decreased obviously when compared with that at the end of PE therapy （P 〈 0.01） and it was not present by the next morning. No new bleeding occurred and the original bleeding did not deteriorate during and after PA plus PE therapy. The main side effects were alkalosis and transient low level of Caion and high level of Catot. CONCLUSION Patients with liver failure still have certain ability to metabolize citrate and tolerate citrate accumulation. RCA may be feasible and safe in the PA plus PE therapy for patients with liver failure.