目的 探讨应用局部枸橼酸抗凝(regional citrate anticoagulation,RCA)行儿童血浆置换(plasma exchange,PE)的效果及安全性。 方法 选取湖南省儿童医院肾脏风湿免疫科2021年2月—2023年6月接受PE治疗且因出血风险评估为中危或以上等级而使用RCA的患儿18例(共48例次)，对照组为同期行肝素抗凝的患儿28例(共84例次)。比较RCA组患儿治疗前、后血钙离子及碳酸氢根离子水平，并比较2组间滤器凝血和患儿出血情况。 结果 RCA-PE治疗期间，患儿治疗1 h及治疗后外周血钙离子水平均较治疗前下降(t=9.543，P＜0.001；t=15.948，P＜0.001)，没有患儿治疗后血钙离子低于0.7 mmol/L。患儿治疗后血碳酸氢根离子水平较治疗前上升(t=9.942，P＜0.001)，治疗后代谢性碱中毒发生率高于治疗前(χ2=10.723，P＜0.001)。所有患儿均未发生需中断治疗的体外循环凝血事件，治疗后评估滤器凝血等级，RCA组患儿滤器凝血率与肝素组无显著差别(χ2=0.475，P=0.488)，RCA组滤器后离子钙＜0.45 mmol/L的患者抗凝有效率高于滤器后离子钙≥0.45 mmol/L的患者(P=0.005)。所有患儿治疗中均未出现肢体麻木、肌肉痉挛、心律失常等低钙血症症状。 结论 儿童血浆置换治疗时使用局部枸橼酸抗凝模式较为简便，局部枸橼酸抗凝能安全、有效的用于儿童血浆置换治疗。
Objective To explore the efficacy and safety of regional citrate anticoagulation (RCA) method for plasma exchange (PE) in children. Method Eighteen children received PE treatment in a total of 48 times at the Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital from February 2021 to June 2023 were enrolled in this study; they were used RCA for PE because they had medium or above medium bleeding risk after a bleeding risk assessment. The control group consisted of 28 children using heparin anticoagulation for PE in a total of 84 times in the same period. Blood calcium ion and bicarbonate ion were compared before and after the treatment in RCA group. Bleeding and clotting in filters were compared between RCA group and control group. Result In RCA group, calcium ion in peripheral blood decreased significantly on PE for 1h and after PE as compared to the blood calcium ion before PE (1.00±0.10 vs. 1.18±0.09, t=9.543, P＜0.001; 0.88±0.13 vs. 1.18±0.09, t=15.948, P＜0.001), but no patients had blood calcium ion ＜0.7mmol/L after PE; blood bicarbonate ion after PE increased significantly as compared to the level before PE (32.53±4.44 vs. 28.29±4.53, t=9.942, P＜0.001); the rate of metabolic alkalosis was higher after PE than before PE (83.33% vs. 45.83%, c2=10.723, P＜0.001). All patients had no extracorporeal circulation coagulation events that interrupted the treatment. The rate of clotting in filters had no significant difference between RCA group and control group (4.17% vs. 7.14%, c2=0.475, P=0.488). In RCA group, the effective anticoagulation rate was higher in the patients with the after filter calcium ion concentration ＜0.45mmol/L than in those with the concentration ≥0.45mmol/L (97.73% vs. 75.00%, P=0.005). There was no significant difference in bleeding between the two groups. The symptoms of hypocalcemia such as limb numbness, muscle twitching or arrhythmia during PE were not found in all of the patients. Conclusion The use of RCA for pediatric plasma exchange therapy is relatively simple and safe. This method can be effectively used for pediatric plasma exchange therapy.
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