目的 观察使用含钙透析液和置换液的局部枸橼酸抗凝(regional citrate anticoagulation，RCA)技术在连续性肾脏替代治疗(continuous renal replacement treatment，CRRT)中的安全性及有效性。 方法 前瞻性收集2020年1月—2021年12月在四川大学华西医院行CRRT的患者，采用枸橼酸抗凝方案的连续性静脉-静脉血液透析滤过(continuous veno-venous haemodiafiltration,CVVHDF)模式。血管通路采用颈内/股静脉留置双腔导管，起始血流量为150 ml/min，含钙透析液和置换液速度均为1000 ml/h，4%枸橼酸钠溶液以180 ml/h的起始速度泵入。治疗过程中分别在0 、6、12、24、48小时测定滤前及滤后游离钙水平，收集体外循环管路寿命、治疗参数以及并发症等。 结果 共纳入28例患者，44例次体外循环管路，42例次按计划CRRT，平均体外循环管路寿命为(44.0±24.6)h，体外循环管路寿命＜24小时共11例(26.2%)，24小时≤体外循环管路寿命＜48小时共13例(31.0%)，48小时≤体外循环管路寿命≤72小时共18例(42.9%)。治疗6小时(t=0.612，P=0.969)、12小时(t=0.456，P=0.625)、24小时(t=0.848，P=0.298)、48小时(t=0.411，P=0.415)滤前钙离子水平与基线(0小时)外周血游离钙离子比较均无统计学差异。治疗6小时(t=0.294，P=0.774)、12小时 (t=0.246，P=0.405)、24小时(t=0.191，P=0.853)、48小时(t=0.059，P=0.955)滤后钙离子水平与基线(0小时)滤后钙离子比较均无统计学差异。1例次(2.3%)患者出现代谢性碱中毒，1例次(2.3%)出现枸橼酸蓄积。 结论 采用含钙透析液和置换液的RCA技术在CRRT中是安全且有效的，适用于含一体化枸橼酸抗凝系统的CRRT设备，值得临床进一步推广应用。
Objective To observe the effectiveness and safety of calcium-containing dialysate and replacement fluid with regional citrate anticoagulation in continuous renal replacement treatment (CRRT). Methods We prospectively recruited the patients treated with CRRT in West China Hospital of Sichuan University during January 2020 to December 2021. They were treated with the model of continuous veno-venous hemodiafiltration (CVVHDF) using citrate anticoagulation method. Blood access used the cuffed catheter in internal jugular vein or femoral vein. The initial blood flow was 150 ml/min, the rate of calcium-containing dialysate and replacement fluid was 1,000 ml/h, and 4% sodium citrate solution was pumped at the initial rate of 180 ml/h. Calcium ion was measured before and after the filtration at 0h, 6h, 12h, 24h and 48h. Lifespan of the extracorporeal circulation pipeline, treatment parameters and complications were collected. Results A total of 28 patients were enrolled in this study, including 44 times of extracorporeal circulation pipeline and 42 times of scheduled CRRT. The average lifespan of the extracorporeal circulation pipeline was 44.0±24.6h, including the lifespan of <24h in 11 cases (26.2%), 24h ～ ＜48h in 13 cases (31.0%), and 48h ～≤72h in 18 cases (42.9%). There were no significant differences in the levels of calcium ion before filtration at 6h (t=0.612, P=0.969), 12h (t=0.456, P=0.625), 24h (t=0.848, P=0.298) and 48h (t=0.411, P=0.415), as compared with the baseline level at 0h. There were also no significant differences in the levels of calcium ion after filtration at 6h (t=0.294, P=0.774), 12h (t=0.246, P=0.405), 24h (t=0.191, P=0.853) and 48h (t=0.059, P=0.955), as compared with the level at 0h. Metabolic alkalosis was found in one patient (2.3%), and citric acid accumulation was found in one patient (2.3%). Conclusion The calcium-containing dialysate and replacement fluid with regional citrate anticoagulation for CRRT is effective and safe, and is suitable for the use of CRRT equipment with integrated citrate anticoagulation system. This method is worthy of further clinical application.
[1] 付平. 连续性肾脏替代治疗[M]. 北京: 人民卫生出版社, 2016: 3.
[2] Ronco C. Evolution of technology for continuous renal replacement therapy: forty years of improvements[J]. Contrib Nephrol, 2017,189: 114-123.
[3]Anantharaman S, Chionh CY. Correcting hyponatremia by fluid sodium modulation in continuous renal replacement therapy with regional citrate anticoagulation[J]. Semin Dial. 2022 Mar;35(2):198-203.
[4] Rhee H, Berenger B, Mehta RL, et al. Regional citrate anticoagulation for continuous kidney replacement therapy with calcium-containing solutions: A cohort study[J]. Am J Kidney Dis, 2021,78(4) 550-559.
[5]席春生,刘同存,蔡蕊莲等.含钙透析液和置换液局部枸橼酸抗凝连续静脉静脉血液透析滤过临床观察[J].中国血液净化,2022,21(08):576-579.
[6]Tiantian W,Xin T,Ling Z, et al. Calcium-containing versus calcium-free replacement solution in regional citrate anticoagulation for continuous renal replacement therapy: a randomized controlled trial[J]. Chinese Medical Journal,2022,135(20).
[7]Zhang L, Liao Y, Xiang J, Qin W, Wu X, Tang Y, et al. Simplified regional citrate anticoagulation using a calcium-containing replace ment solution for continuous venovenous hemofiltration. J Artif Organs 2013;16:185–192.
[8]Ong SC, Wille KM, Speer R, Tolwani AJ. A continuous veno venous hemofiltration protocol with anticoagulant citrate dextrose formula A and a calcium-containing replacement fluid. Int J Artif Organs 2014;37:499–502.
[9]张凌,李佩芸,魏甜甜等.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[J].华西医学,2018,33(07):838-842.
[10]?Kaewdoungtien P, Tachaboon S, Kangsumrith N, Srisawat N. Immunomodulation Effect of Regional Citrate Anticoagulation in Acute Kidney Injury Requiring Renal Replacement Therapy[J]. Blood Purif. 2023;52(5):474-482.?
[11]?Legrand M, Tolwani A. Anticoagulation strategies in continuous renal replacement therapy[J]. Semin Dial. 2021 Nov;34(6):416-422.?
[12] 董晓辉,徐岩.连续性肾脏替代治疗置换液的应用现状[J].齐鲁医学杂志,2011,26(04):374-376.
[13] Bianchi NA, Altarelli M, Eckert P, Schneider AG. Complications of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy: An Observational Study[J]. Blood Purif. 2020;49(5):567-575.?
[14]韩锦, 王欣, 李侠,等 . 枸橼酸盐两段式抗凝在含钙置换液连续性肾脏替代治疗中的抗凝效果[J]. 山西医科大学学报, 2019,50(12):1750-1754.
[15]Kirwan CJ, Hutchison R, Ghabina S, Schwarze S, Beane A, Ramsay S, Thompson E, Prowle JR. Implementation of a Simplified Regional Citrate Anticoagulation Protocol for Post-Dilution Continuous Hemofiltration Using a Bicarbonate Buffered, Calcium Containing Replacement Solution[J]. Blood Purif. 2016;42(4):349-355.?
