319例肝病患者持续肾脏替代治疗的管路寿命及影响因素分析

Circuit lifespan during continuous renal replacement therapy in 319 patients with hepatic insufficiency

目的 评估不同抗凝方式对肝功能不全患者持续肾脏替代治疗(continuous renal replacement therapy,CRRT)管路寿命和并发症的影响。方法 回顾性分析北京佑安医院近12年进行CRRT治疗的319例肝病患者资料,对比全身肝素、枸橼酸钠局部抗凝与无抗凝对管路寿命和并发症的影响,分析影响管路寿命的危险因素。结果 无抗凝的管路寿命为10(6,21)h,肝素抗凝为13(9,23)h(P=0.203),枸橼酸钠局部抗凝为21(11,56)h,较肝素显著延长(P=0.000)。肝素抗凝组的出血发生率为30.8%,显著高于未抗凝组的11.4%和枸橼酸钠抗凝组的4.2%(P=0.000)。枸橼酸钠局部抗凝组总钙/离子钙>2.5发生率为25.8%,代谢性酸中毒和代谢性碱中毒发生率分别为16.8%和12.1%,均高于其他2组(P<0.05)。多因素COX比例风险模型回归分析显示,肝衰竭(HR=1.49,95%CI:1.16~1.90)和非枸橼酸局部抗凝(HR=0.51,95%CI:0.43~0.62)是肝病患者管路寿命<48 h的危险因素(P<0.005)。结论 肝病患者CRRT的管路寿命较短,肝素不能带来临床益处,枸橼酸钠局部抗凝延长管路寿命,但枸橼酸蓄积的发生率增加,肝衰竭和非枸橼酸局部抗凝与管路寿命<48 h相关。

Objective To evaluates the circuit lifespan and complications of CRRT in patients with hepatic insufficiency using different anticoagulation agents.Methods Retrospective analysis of 319 patients with severe liver injury treated with CRRT in the Department of critical medicine of Beijing You'an Hospital in recent 12 years.The effects of systemic heparin,regional citrate anticoagulation(RCA)and non-anticoagulation on circuit lifespan and complications were analyzed.The risk factors affecting circuit lifespan were analyzed.Results The circuit lifespan without anticoagulation was 10(6,21)hours and was not prolonged by heparin in patients with hepatic insufficiency[13(9,23),P=0.203].The circuit lifespan was 21(11,56)h anticoagulated with citrate,which was significantly longer than heparin(P=0.000).Bleeding occurred in 30.8%of patients with heparin,while it was 4.2%in RCA.But,the incidence of total calcium/ionized calcium>2.5 was 25.8%and the incidence of metabolic acidosis and metabolic alkalosis were 16.8 and 12.1%respectively,which were higher than those in the other two groups(P<0.05).Multivariate Cox regression proportional hazards model analysis revealed that liver failure(HR=1.49,95%CI:1.16~1.90)and non-citrate anticoagulation(HR=0.51,95%CI:0.43~0.62)were risk factors for circuit life<48h.Conclusion The circuit lifespan of CRRT in patients with hepatic insufficiency was shortened.Heparin does not provide clinical benefits.RCA can prolong the circuit lifespan but the citrate accumulation must be cautious about.Liver failure and non-RCA were linked to circuit lifespans<48 hours in patients with liver disease.