应用普通含钙透析液局部枸橼酸抗凝血液透析的临床观察

摘要

目的 探讨应用普通含钙透析液进行局部枸橼酸抗凝(regional citrate anticoagulation,RCA)血液透析(hemodialysis,HD)治疗的有效性和安全性.方法 选择63例行HD治疗的高危出血患者,随机分为RCA组(30例,治疗87例次)和无肝素组(33例,治疗68例次).RCA组在线调整透析液离子浓度,4％枸橼酸三钠从透析管路动、静脉端分别输入.检测透析充分性、治疗前后凝血功能、PH值及电解质变化.记录患者生命体征、透析器凝血及临床出血事件. 结果 ①RCA组溶质清除指数(Kt/V高于无肝素组(1.2±0.3比0.9±0.2,t=3.257,P=0.002),治疗时间长于无肝素组[(4.0±0.0)h比(3.1±0.5)h,t=5.177,P＜0.001].②RCA组透析器凝血情况好于无肝素组(P＜0.001).③RCA组治疗后凝血功能无明显变化,PH值(t=-4.590,P＜0.001)、Na-(t=-2.431,P=0.021)及HC03(t=-4.630,P＜0.001)较治疗前上升,但在正常范围内.治疗前后Ca2-无明显变化(t=1.708,P=0.097).④2组患者治疗过程中生命体征稳定,无出血事件发生.结论 通过在线调整透析液离子浓度及枸橼酸分2部分输入的方法,可以应用普通含钙透析液对高危出血患者进行RCA血液透析.治疗过程中需要监测血气分析及相关离子变化,以减少并发症.%Purpose To assess the efficacy and safety of regional citrate anticoagulation (RCA) with routine dialysate containing calcium in hemodialysis patients.Methods Sixty-three hemodialysis patients at high risk of bleeding were randomly divided into two groups:RCA group (30 patients,87 dialysis sessions) and heparin-free group (33 patients,68 dialysis sessions).In RCA group,electrolyte concentrations were adjusted on-line,and 4％ sodium citrate was infused into the arterial line and vein line in the dialyzer.Kt/V,function of the coagulation system,acid-base and electrolyte were monitored pre-and post-hemodialysis.The vital signs of the patients during hemodialysis,dialyzer clotting and bleeding episodes wcrc recorded.Results ①Kt/V was significantly higher and the mean treatment time was significantly longer in RCA group than in heparin-free group (1.2±0.3 vs.0.9±0.2,t=-3.257,P=0.002 for Kt/V;4.0±0.0 h vs.3.1±0.5 h,t=5.177,P＜ 0.001 for treatment time).②Clotting in dialyzer occurred more frequently in heparin-free group than in RCA group (P＜0.001).③In RCA group,there were no significant differences in the function of the coagulation system and ionized calcium before and after the hemodialysis (t=1.708,P=0.097).pH (t=-4.590,P＜0.001),Na+ (t=-2.431,P=0.021) and HCO3-(t=-4.630,P＜0.001) increased after the hemodialysis but remained in the normal ranges.④Vital signs were stable and no bleeding episodes were found in both groups.Conclusions It is feasible to use RCA with routine dialysate containing calcium for hemodialysis patients at high risk of bleeding by adjusting electrolyte concentrations on-line and infusing sodium citrate into the arterial line before dialyzer and vein dropper.Complications can be prevented by close monitoring of arterial blood gas and electrolytes.