局部枸橼酸抗凝在危重症患者持续肾脏替代疗法中的临床应用

目的 探讨危重症患者连续静脉静脉血液滤过(continuous venous hemofiltration，CVVH)中应用局部枸橼酸抗凝（regional citrate anticoagulation，RCA）的效果及安全性。方法 回顾性分析接受CVVH治疗的668例危重患者的资料，据抗凝方式分为RCA组和普通肝素抗凝组，比较两组急性生理和慢性健康（acute physiology and chronic health，APACHEⅡ）评分、持续肾脏替代疗法（continuous renal replacement therapy，CRRT）治疗原因、滤器寿命、血液滤过中止的原因、并发症。结果 RCA组滤器寿命长于普通肝素组（P＜0.001）。滤器寿命＜24 h者所占比例，肝素抗凝组高于枸橼酸抗凝组，滤器寿命≥48 h者所占比例，肝素抗凝组低于枸橼酸抗凝组，差异有统计学意义(P＜0.05)；滤器寿命在24~48 h者，两组比较差异无统计学意义（P＞0.05)。分析两组血滤中断的原因，枸橼酸抗凝组过滤器凝血比例低于肝素抗凝组，达到治疗目的结束治疗下机比例高于肝素组，橼酸抗凝组治疗超过72 h需要更换滤器比例高于肝素抗凝组，差异有统计学意义(P＜0.05)。两组抗凝均无严重出血事件。治疗后，两组血清总Ca2+、动脉血pH 、游离Ca2+、Na+ 、HCO3-比较差异无统计学意义(P＞0.05)。结论 与肝素抗凝相比较，危重症患者行CVVH时使用RCA，可明显延长滤器寿命，减少耗材的应用，无明显代谢并发症及出血风险，有望成为ICU患者CVVH治疗的一线抗凝方式。

Clinical application of regional citrate anticoagulation in continuous renal replacement therapy in critically ill patients

Objective To investigate the efficacy and safety of regional citrate anticoagulation(RCA) in continuous venous hemofiltration(CVVH) in critically ill patients.Methods A retrospective analysis of the general data of 668 critically ill patients who received CVVH treatment was performed.They were divided into the RCA group and unfractionated heparin(UFH) group based on anticoagulation methods. The acute physiology and chronic health(APACHEⅡ) score, causes of treatment with continuous renal replacement therapy(CRRT), filter life, reasons for suspension of hemofiltration, and complications between two groups were compared in both groups.Results The filter life of RCA group was longer than that of UFH group(P＜0.001). The proportion of filter life＜24 h in UFH group was higher than that in RCA group, and the proportion of filter life ≥48 h in UFH group was lower than that in RCA group, with significant difference(P＜0.05). There was no significant difference between two groups when the filter life was 24-48 h(P＞0.05). The causes of suspension of hemofiltration in two groups were analyzed. The coagulation ratio of filter in RCA group was lower than that in UFH group, the proportion of getting off the machine at the end of treatment was higher than that in UFH group, and the proportion of replacing filter in RCA group was higher than that in UFH group after treatment for more than 72 h(P＜0.05). There were no serious bleeding events in both groups. After treatment, there was no significant difference in serum total Ca2+, arterial blood pH, free Ca2+, Na+, HCO3- between two groups(P＞0.05).Conclusion Compared with UFH anticoagulation, RCA in critically ill patients undergoing CVVH can significantly prolong the filter life, reduce the application of supplies, and have no obvious metabolic complications or bleeding risk. It is expected to be the first-line anticoagulation method for CVVH treatment in ICU patients.