【摘要】抗凝是血液净化能够顺利完成的先决条件。目前临床经典的抗凝方式以肝素、低分子肝素为主，但枸橼酸钠抗凝以其安全、有效、应用范围更广、生物相容性更优的特点，被广泛用于持续血液净化，并得到国内外指南的推荐；在其他不同血液净化模式中，大量的研究也证实枸橼酸钠是1 种理想抗凝剂。然而在实践过程中，发现枸橼酸钠抗凝在监测和调整上步骤繁复，存在较多潜在副作用。因此许多学者提出了优化方案并进行了探索和尝试，为枸橼酸钠能够在血液净化中更好发挥抗凝作用提供更多思路。本文就枸橼酸钠在不同血液净化模式中的抗凝方案的监测和调整的进展进行回顾。
【Abstract】Anticoagulation is of major importance for successful performance of blood purification. Currently, the classic anticoagulation methods are heparin and low molecular weight heparin. Regional anticoagulation of citrate (RCA) is now widely used for continuous blood purification due to its safety, effectiveness, wider application range and better biocompatibility. RCA has been recommended in domestic and foreign guidelines. Citrate anticoagulation is an ideal method, which has been confirmed by a large number of studies in different blood purification modalities. However, citrate has several drawbacks found in clinical practice, including complicated monitoring and adjustment and many potential side effects. Optimized protocols of citrate anticoagulation are therefore explored and recommended in order to provide new ways for the better use of citrate as an anticoagulation agent in blood purification. In this paper, we review the progress in monitoring and adjusting RCA in different blood purification modalities.
[1]Kirwan, C.Implementation of a Simplified Regional Citrate Anticoagulation Protocol for Post-Dilution Continuous Hemofiltration Using a Bicarbonate Buffered, Calcium Containing Replacement Solution. Blood Purif, 2016. 42(4): p. 349-355.[J].blood purification, 2016, 42(4):349-355
[2]Tolwani, A.Advances in continuous renal replacement therapy: citrate anticoagulation update. Blood Purif, 2012. 34(2): p. 88-93.[J].blood purification, 2012, 34(2):88-93
[3]Calatzis, A.Citrate anticoagulation for extracorporeal circuits: effects on whole blood coagulation activation and clot formation. Nephron, 2001. 89(2): p. 233-6.[J].Nephron, 2001, 89(2):233-236
[4]Khwaja, A.KDIGO clinical practice guidelines for acute kidney injury. [J].Nephron Clin Pract, 2012, 120(4):179-184
[5]Ronco, C.Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial.[J].EDTNA ERCA J, 2002, Suppl 2: p. 7-12.(2):7-12
[6]Bolan, C.Controlled study of citrate effects and response to i.v. calcium administration during allogeneic peripheral blood progenitor cell donation. [J].Transfusion, 2002, 42(7):935-946
[7]Weidhase, L.Middle molecule clearance with high cut-off dialyzer versus high-flux dialyzer using continuous veno-venous hemodialysis with regional citrate anticoagulation: A prospective randomized controlled trial. [J].PLoS One, 2019, 14(4):-
[8]Gao, J.A mode of CVVH with regional citrate anticoagulation compared to no anticoagulation for acute kidney injury patients at high risk of bleeding.[J].Sci Rep, 2019, 9(1):6607-6607
[9]Gao, J., et al., A mode of CVVH with regional citrate anticoagulation compared to no anticoagulation for acute kidney injury patients at high risk of bleeding. Sci Rep, 2019. 9(1): p. 6607.
[10]Zheng, Y., et al., Calcium supplementation in CVVH using regional citrate anticoagulation. Hemodial Int, 2019. 23(1): p. 33-41.
[11]Yu, W., et al., Optimized Calcium Supplementation Approach for Regional Citrate Anticoagulation. Nephron, 2019. 141(2): p. 119-127.
[12]Tolwani, A.J., et al., A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance. Clin J Am Soc Nephrol, 2006. 1(1): p. 79-87.
[13]Gupta, M., N.K. Wadhwa and R. Bukovsky, Regional citrate anticoagulation for continuous venovenous hemodiafiltration using calcium-containing dialysate. Am J Kidney Dis, 2004. 43(1): p. 67-73.
[14]Caruana, R.J., et al., Heparin free dialysis: comparative data and results in high risk patients. Kidney Int, 1987. 31(6): p. 1351-5.
[15]张东亮, 张潘与张周沧, 分段枸橼酸抗凝进行含钙透析液高通量血液透析的临床观察.中国血液净化, 2016. 15(12): 第686-690页.
[16]席春生等, 高出血风险患者两段法枸橼酸抗凝血液透析的临床观察.临床肾脏病杂志, 2018. 18(03): 第141-144页.
[17]朱淑华等, 简化枸橼酸抗凝无肝素透析的疗效观察.肾脏病与透析肾移植杂志, 2017. 26(04): 第323-327页.
[18]毕晓红等, 枸橼酸钠抗凝在血液透析滤过治疗中的效果观察.临床肾脏病杂志, 2019. 19(02): 第112-115页.
[19]Lee, C.Y., H.C. Yeh and C.Y. Lin, Treatment of critically ill children with kidney injury by sustained low-efficiency daily diafiltration. Pediatr Nephrol, 2012. 27(12): p. 2301-9.
[20]Sethi, S.K., et al., Feasibility of sustained low efficiency dialysis in critically sick pediatric patients: A multicentric retrospective study. Hemodial Int, 2018. 22(2): p. 228-234.
[21]Kielstein, J.T., M. Schiffer and C. Hafer, Back to the future: extended dialysis for treatment of acute kidney injury in the intensive care unit. J Nephrol, 2010. 23(5): p. 494-501.
[22]张凌等, 简化枸橼酸抗凝技术在持续缓慢低效血液透析中的临床应用.华西医学, 2018. 33(07): 第838-842页.
[23]Kaplan, A.A., Therapeutic plasma exchange: core curriculum 2008. Am J Kidney Dis, 2008. 52(6): p. 1180-96.
[24]Clark, W.F., Plasma exchange for renal disease: evidence and use 2011. J Clin Apher, 2012. 27(3): p. 112-6.
[25]Kissling, S., et al., A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges. BMC Nephrol, 2017. 18(1): p. 81.
[26]van der Voort, P.H., et al., An observational study on the effects of nadroparin-based and citrate-based continuous venovenous hemofiltration on calcium metabolism. Blood Purif, 2007. 25(3): p. 267-73.
[27]Evenepoel, P., et al., Regional citrate anticoagulation for hemodialysis using a conventional calcium-containing dialysate. Am J Kidney Dis, 2002. 39(2): p. 315-23.
[28]Richtrova P, Rulcova K, Mares J, Reischig T.Evaluation of three different methods to prevent dialyzer clotting without causing systemic anticoagulation effect. Artif Organs. 2011; 35:83–88.
[29]Sagedal S, Hartmann A, Osnes K, et al.Intermittent saline flushes during haemodialysis do not alleviate coagulation and clot formation in stable patients receiving reduced doses of dalteparin.Nephrol Dial Transplant.2006; 21:444–449.
