目的 旨在探讨枸橼酸局部抗凝(regional citrate anticoagulation,RCA)下连续性肾脏替代治疗(continuous renal replacement therapy，CRRT)中血乳酸水平对体外循环凝血的影响。 方法 采用回顾性队列研究设计，收集广州医科大学附属第二医院重症医学科2021年6月—2023年7月局部枸橼酸抗凝下行CRRT治疗的体外循环数据，根据48小时内是否凝血下机分为凝血组和非凝血组。采用COX回归分析CRRT体外循环48小时内凝血的危险因素。 结果 共纳入114例患者，共179套CRRT体外循环和对应数据，其中凝血组105例，非凝血组74例。COX回归分析显示：静脉压高(HR=1.008，95% CI：1.000～1.016，P =0.045)、乳酸≥2 mmol/L(HR =1.517，95% CI：1.009～2.280，P =0.045)是CRRT体外循环48小时内凝血的独立危险因素；枸橼酸剂量≥3.2 mmol/L(HR =0.461，95%CI：0.312～0.682,P＜0.001)是其保护因素。 结论 CRRT上机时应对体外循环进行充分预冲，运行前测试血液透析置管功能，调整好血液透析置管位置以避免静脉压升高。乳酸高，组织灌注差的患者应积极液体复苏，避免血液过度浓缩，有助于降低CRRT体外循环48小时内凝血的风险。
Objective This retrospective study aimed to identify factors contributing to clotting within 48 hours in circuits of continuous renal replacement therapy (CRRT) using regional citrate anticoagulation (RCA). Methods Data from the intensive care unit of the Second Affiliated Hospital of Guangzhou Medical University between June 2021 and July 2023 were analyzed. Circuits were categorized into clotting and non-clotting groups based on 48-hour clotting occurrence. COX regression analysis was performed to identify clotting risk factors. Results A total of 114 patients with 179 sets of CRRT circuits and corresponding data were included in the study. Among them, clotting within 48 hours of initiation was observed in 105 cases, while 74 cases did not experience clotting within 48 hours. Venous pressure (HR=1.008, 95% CI: 1.0～1.016, P=0.045)and lactate level ≥2 mmol/L (HR=1.517, 95% CI：1.009～2.280, P=0.045) were identified as independent risk factors for circuit clotting within 48 hours of CRRT. On the other hand, citrate dose ≥3.2 mmol/L (HR=0.461, 95% CI：0.312～0.682, P＜0.001) was identified as a protective factor. Conclusion In continuous renal replacement therapy using regional citrate anticoagulation, high venous pressure, increased platelet count, and elevated lactate levels were associated with increased clotting risk within 48 hours. Pre-filling circuits adequately and optimizing catheter positioning before CRRT initiation are recommended. Managing patients with high lactate levels and impaired tissue perfusion through fluid resuscitation can reduce clotting risk.
[1]Zhang X, Yuan Y.Effect of replacement therapy (CRRT) and hemodialysis (IHD) on severe acute renal failure[J].[J].Frontiers in pharmacology, 2023, 14(1):112778
[2]Matsuura R, Doi K, Hamasaki Y, et al.RRT Selection for AKI Patients With Critical Illness[J].Seminars in Nephrology, 2020, 40(5):498-505
[3]Karkar A, Ronco C.Prescription of CRRT: a pathway to optimize therapy[J].Ann Intensive Care, 2020, 10(1):32-32
[4]Lee KH, Sol IS, Park JT, et al.Continuous Renal Replacement Therapy (CRRT) in Children and the Specialized CRRT Team: A 14-Year Single-Center Study[J].Journal of clinical medicine, 2019, 9(1):110-110
[5]Cardinale M, Cungi P J, Meaudre E.Green plasma and a blocked CRRT circuit due to drug-induced hyperlipidemia[J].Intensive Care Med, 2019, 45(9):1305-1306
[6]Brain M, Winson E, Roodenburg O, et al.Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis[J].BMC Nephrol, 2017, 18(1):69-69
[7]Li L, Bai M, Zhang W, et al.Regional citrate anticoagulation versus low molecular weight heparin for CRRT in hyperlactatemia patients: A retrospective case-control study[J].The International Journal of Artificial Organs, 2022, 45(4):343-350
[8]Schneider AG, Joannes-Boyau O.Regional citrate anticoagulation for CRRT: Still hesitating?[J].Anaesth Crit Care Pain Med, 2021, 40(2):100855
[9]Stucker F, Ponte B, Tataw J, Martin PY, Wozniak H, Pugin J, Saudan P.Efficacy and safety of citrate-based anticoagulation compared to heparin in patients with acute kidney injury requiring continuous renal replacement therapy: a randomized controlled trial[J].Crit Care, 2015, 19(1):91-91
[10]Khwaja A.KDIGO clinical practice guidelines for acute kidney injury[J].Nephron Clin Pract, 2012, 120(4):c179-184
[11]中华医学会肾脏病学分会专家组.连续性肾脏替代治疗的抗凝管理指南[J].中华肾脏病杂志, 2022, 38(11):1016-1024
[12]张鹏, 张辉, 张爽, 等.局部枸橼酸抗凝行连续性肾替代治疗对乳酸升高重症患者的效果[J].实用医学杂志, 2022, 38(7):863-867
[13]田丽, 王建刚, 刘新宇.枸橼酸抗凝在乳酸酸中毒患者连续性肾脏替代治疗中的应用价值[J].临床肾脏病杂志, 2019, 19(3):176-180
[14]Hartemink K J, Hack C E, Groeneveld AB.Relation between coagulationfibrinolysis and lactate in the course of human septic shock[J].Journal of Clinical Pathology, 2010, 63(11):1021-1026
[15]费素定, 金静芬, 王海燕等.连续性肾脏替代治疗非计划性下机时间相关因素的研究[J].中华护理杂志, 2015, 50(01):57-61
[16]Kakajiwala A, Jemielita T, Hughes JZ, et al.Membrane pressures predict clotting of pediatric continuous re nal replacement therapy circuits[J].Pediatr Nephrol, 2017, 32(7):1251-1261
[17]李克佳, 胡军, 苏琳等.重症患者连续性肾脏替代治疗非计划下机的相关因素研究[J].中国血液净化, 2020, 19(09):645-648
[18]杨其霖，张尹州，孔田玉, 等.血清乳酸水平与重症患者病死率的相关研究[J].中华危重病急救医学, 2020, 32(06):737-742
[19]Roosterman D, Cottrell GS.Rethinking the Citric Acid Cycle: Connecting Pyruvate Carboxylase and Citrate Synthase to the Flow of Energy and Material[J].Int J Mol Sci, 2021, 22(2):604-606
[20]Tan JN, Haroon S, Mukhopadhyay A, et al.Hyperlactatemia predicts citrate intolerance with regional citrate anticoagulation during continuous renal replacement therapy[J].J Intensive Care Med, 2019, 34(5):418-425
