Objective To compare and explore the efficacy of regional citrate anticoagulation therapy and regional heparin anticoagulation therapy in continuous renal replacement therapy (CRRT) of acute kidney injury (AKI) patients with risk of bleeding by an retrospective study. Methods A total of 96 AKI patients with risk of bleeding were collected retrospectively and treated with CRRT. All the patients were divided into two groups: regional citrate group (n=50) and regional heparin group (n=46). APTT, level of Ca2+, pH value, levels of HCO3- and Na+, time of blood filter using and incidence of adverse events were compared between the two groups. Results Percentage of hypernatremia, metabolic alkalosis and elevation of transaminase in regional citrate group were 2.3%, 6.1%, 1.9%, respectively, those in the regional heparin group were 1.6%, 0.9%, 1.6%, respectively. The time of blood filter using in regional citrate group and regional heparin group were (70.0±5.3) h and (48.0±2.7) h, respectively (P<0.05). Incidence of bleeding event in regional citrate group and regional heparin group were 3.8% and 13.0%, respectively (P<0.05). Conclusion In patients with coagulation disorders or bleeding risk undergoing CRRT, regional citrate anticoagulation therapy is safer and more effective, and worthy of promotion.
表3
两组患者行CRRT治疗后高钠血症、代谢性碱中毒和转氨酶升高的比例
Tab.3
Percentage of hypernatremia, metabolic alkalosis and transaminase elevation in two groups of patients after CRRT treatment %
组别
例数
高钠血症
代谢性碱中毒
转氨酶升高
体外肝素组
46
1.6
0.9
1.6
体外枸橼酸组
50
2.3
6.1*1
1.9
Compared with regional heparin group,t=0.014, *1P<0.05
与体外肝素组比较,t=0.014,*1P<0.05
表3
两组患者行CRRT治疗后高钠血症、代谢性碱中毒和转氨酶升高的比例
Tab.3
Percentage of hypernatremia, metabolic alkalosis and transaminase elevation in two groups of patients after CRRT treatment %
JOHN AK,NORBERTL.Diagnosis,evaluation,and manage-ment of acute kidney injury:a KDIGO summary(Part 1)[J].Crit Care,2013,17(1):204.
Abstract Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided.
PARK JS,KIM GH,KANG CM,et al.Regional anticoagu-lation with citrate is superior to systemic anticoagulation with heparin in critically ill patients undergoing continuous venovenous hemodiafiltration[J].Korean J Intern Med,2011,26(1):68-75.
Short hemofilter survival and anticoagulation-related life-threatening complications are major problems in systemic anticoagulation with heparin (SAH) for continuous renal replacement therapy (CRRT). The present study examined if regional anticoagulation with citrate (RAC) using commercially available solutions can overcome the associated problems of SAH to produce economical benefits. Forty-six patients were assigned to receive SAH or RAC. We assessed the coagulation state, clinical outcomes, and adverse events. A Kaplan-Meier analysis was used to estimate hemofilter life span. The economical benefit related to the prolonged hemofilter survival was examined on the basis of the average daily cost. The mean age of patients was 66.5 卤 13.8 years and the majority were male (60.9%). While elective discontinuation was most common cause of early CRRT interruption in the RAC group (34.3%, p < 0.01), hemofilter clotting was most prevalent in the SAH group (82.2%, p < 0.01). The patient metabolic and electrolyte control and survival rate were not different between the two groups. When compared with the RAC group, the anticoagulation-associated bleeding was a major complication in the SAH group (15.0% vs. 61.5%, p < 0.01). Regional anticoagulated hemofilters displayed a significantly longer survival time than systemic anticoagulated hemofilters (59.5 卤 3.8 hr vs. 15.6 卤 1.3 hr, p < 0.01). Accordingly, the mean daily continuous venovenous hemodiafiltration costs in the RAC and SAH groups were $575 卤 268 and $1,209 卤 517, respectively (p < 0.01). RAC prolonged hemofilter survival, displaying an economical benefit without severe adverse effects. The present study therefore demonstrates that RAC, using commercially available solutions, may be advantageous over SAH as a cost-effective treatment in CRRT.
LEVI TM,DE SOUZA S P,DE MAGALHAES J G,et al.Comparison of the RIFLE,AKIN and KDIGO criteria to predict mortality in critically ill patients[J].Rev Bras Ter Intensiva,2013,25(4):290-296.
Abstract OBJECTIVE: Acute kidney injury is a common complication in critically ill patients, and the RIFLE, AKIN and KDIGO criteria are used to classify these patients. The present study's aim was to compare these criteria as predictors of mortality in critically ill patients. METHODS: Prospective cohort study using medical records as the source of data. All patients admitted to the intensive care unit were included. The exclusion criteria were hospitalization for less than 24 hours and death. Patients were followed until discharge or death. Student's t test, chi-squared analysis, a multivariate logistic regression and ROC curves were used for the data analysis. RESULTS: The mean patient age was 64 years old, and the majority of patients were women of African descent. According to RIFLE, the mortality rates were 17.74%, 22.58%, 24.19% and 35.48% for patients without acute kidney injury (AKI) in stages of Risk, Injury and Failure, respectively. For AKIN, the mortality rates were 17.74%, 29.03%, 12.90% and 40.32% for patients without AKI and at stage I, stage II and stage III, respectively. For KDIGO 2012, the mortality rates were 17.74%, 29.03%, 11.29% and 41.94% for patients without AKI and at stage I, stage II and stage III, respectively. All three classification systems showed similar ROC curves for mortality. CONCLUSION: The RIFLE, AKIN and KDIGO criteria were good tools for predicting mortality in critically ill patients with no significant difference between them.
TIAN HL,ZENGR,WANG XJ,et al.The effects of conti-nuous blood purification for SIRS/MODS patients:a systematic review and meta-analysis of randomized controlled trials[J].Hematol,2012,2012:986795.
Abstract Background. Continuous veno-venous hemofiltration (CVVH) has aroused great concern in recent years because its effect on clearing inflammatory mediators and its mechanism of clinical effects in the treatment of critical illness has also become a research direction. Objective. To evaluate the efficacy of continuous blood purification for systemic inflammatory response syndrome (SIRS)/multiple organ dysfunction syndrome (MODS) patients. Methods. A systematic review of the literature was undertaken to assess randomized controlled trials on CVVH. Results. 11芒聙聣RCTs involving a total of 414 patients were included. Compared with the control group, CVVH for SIRS/MODS patients has several advantages including better effects on clearing the plasma inflammatory mediators IL-6 [SMD(3d) = -0.45, 95%CI, (-0.83, -0.07), SMD(7d) = -1.07, 95%CI, (-1.52, -0.62)], on plasma TNF-alfa [SMD(3d) = -0.87, 95%CI, (-1.69, -0.04), SMD(7d) = -1.42, 95%CI, (-2.49, -0.35)], lower white blood cell (WBC) count [MD = 2.61, 95%CI, (1.49, 3.73)], shorter hospital stays [MD = -7.21 days, 95%CI, (-10.68, -3.74)] and better stability of hemodynamics. However, there is no significant difference in the mortality rate [MODS:RR = 0.62, 95%CI, (0.38, 1.01), SIRS:RR = 0.75, 95%CI, (0.57, 1.08)]. Conclusions. The study showed that CVVH was able to eliminate inflammatory mediators (TNF-alfa, IL-6) in plasma effectively, lower WBC count and shorter hospital stays than conventional therapeutic measures.
FERNANDEZ SN,SANTIAGO MJ,JESUS LH,et al.Citrate anticoagulation for CRRT in children:comparison with heparin[J].Biomed Res Int,2014,2014:786301.
Abstract Regional anticoagulation with citrate is an alternative to heparin in continuous renal replacement therapies, which may prolong circuit lifetime and decrease hemorrhagic complications. A retrospective comparative cohort study based on a prospective observational registry was conducted including critically ill children undergoing CRRT. Efficacy, measured as circuit survival, and secondary effects of heparin and citrate were compared. 12 patients on CRRT with citrate anticoagulation and 24 patients with heparin anticoagulation were analyzed. Median citrate dose was 2.665mmol/L. Median calcium dose was 0.1665mEq/kg/h. Median heparin dose was 1565UI/kg/h. Median circuit survival was 48 hours with citrate and 31 hours with heparin (P = 0.028). 66.6% of patients treated with citrate developed mild metabolic alkalosis, which was directly related to citrate dose. There were no cases of citrate intoxication: median total calcium/ionic calcium index (CaT/I) of 2.16 and a maximum CaT/I of 2.33, without metabolic acidosis. In the citrate group, 45.5% of patients developed hypochloremia and 27.3% hypomagnesemia. In the heparin group, 27.8% developed hypophosphatemia. Three patients were moved from heparin to citrate to control postoperatory bleeding. In conclusion citrate is a safe and effective anticoagulation method for CRRT in children and it achieves longer circuit survival than heparin.
SPONHOLZC,BAYERO,KABISCHB,et al.Anticoagula-tion strategies in venovenous hemodialysis in critically ill patients:a five-year evaluation in a surgical intensive care unit[J].Scientific World J,2014,2014:808320.
Renal failure is a common complication among critically ill patients. Timing, dosage, and mode of renal replacement (RRT) are under debate, but also anticoagulation strategies and vascular access interfere with dialysis success. We present a retrospective, five-year evaluation of patients requiring RRT on a multidisciplinary 50-bed surgical intensive care unit of a university hospital with special regard to anticoagulation strategies and vascular access. Anticoagulation was preferably performed with unfractionated heparin or regional citrate application (RAC). Bleeding and suspected HIT-II were most common causes for RAC. In CVVHD mode filter life span was significantly longer under RAC compared to heparin or other anticoagulation strategies ( P = 0.001 ). Femoral vascular access was associated with reduced filter life span ( P = 0.012 ), especially under heparin anticoagulation ( P = 0.015 ). Patients on RAC had higher rates of metabolic alkalosis ( P = 0.001 ), required more transfusions ( P = 0.045 ), and showed higher illness severity measured by SOFA scores ( P = 0.001 ). RRT with unfractionated heparin represented the most common anticoagulation strategy in this study population. However, patients with bleeding risk and severe organ dysfunction were more likely placed on RAC. Citrate provided longer filter life spans regardless of vascular access site. Attention has to be paid to metabolic disturbances.
MORABITOS,PISTOLESIV,TRITAPEPEL,et al.Regional citrate anticoagulation in CVVH:a new protocol combining citrate solution with a phosphate-containing replacement fluid[J].Hemodial Int,2013,17(2):313-320.
Regional citrate anticoagulation (RCA) is a valid anticoagulation method in continuous renal replacement therapies (CRRT) and different combination of citrate and CRRT solutions can affect acid-base balance. Regardless of the anticoagulation protocol, hypophosphatemia occurs frequently in CRRT. In this case report, we evaluated safety and effects on acid-base balance of a new RCA- continuous veno-venous hemofiltration (CVVH) protocol using an 18 mmol/L citrate solution combined with a phosphate-containing replacement fluid. In our center, RCA-CVVH is routinely performed with a 12 mmol/L citrate solution and a postdilution replacement fluid with bicarbonate (protocol A). In case of persistent acidosis, not related to citrate accumulation, bicarbonate infusion is scheduled. In order to optimize buffers balance, a new protocol has been designed using recently introduced solutions: 18 mmol/L citrate solution, phosphate-containing postdilution replacement fluid with bicarbonate (protocol B). In a cardiac surgery patient with acute kidney injury, acid-base status and electrolytes have been evaluated comparing protocol A (five circuits, 301 hours) vs. protocol B (two circuits, 97 hours): pH 7.39 ± 0.03 vs. 7.44 ± 0.03 (P < 0.0001), bicarbonate 22.3 ± 1.8 vs. 22.6 ± 1.4 mmol/L (NS), Base excess -2.8 ± 2.1 vs. -1.6 ± 1.2 (P = 0.007), phosphate 0.85 ± 0.2 vs. 1.3 ± 0.5 mmol/L (P = 0.027). Protocol A required bicarbonate and sodium phosphate infusion (8.9 ± 2.8 mmol/h and 5 g/day, respectively) while protocol B allowed to stop both supplementations. In comparison to protocol A, protocol B allowed to adequately control acid-base status without additional bicarbonate infusion and in absence of alkalosis, despite the use of a standard bicarbonate concentration replacement solution. Furthermore, the combination of a phosphate-containing replacement fluid appeared effective to prevent hypophosphatemia.
Regional anticoagu-lation with citrate is superior to systemic anticoagulation with heparin in critically ill patients undergoing continuous venovenous hemodiafiltration
, 刘娇, 邓艳萍
