枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用

doi:10.3877/cma.j.issn.1673-5250.2016.06.020

中华妇幼临床医学杂志(电子版) ›› 2016, Vol. 12 ›› Issue (06) : 726 -730. doi: 10.3877/cma.j.issn.1673-5250.2016.06.020

所属专题：文献；

论著

枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用

郭妍南¹, 明华², 陈秀英¹, 王峥¹^,^†(

)

^1. 610041成都，四川大学华西第二医院儿科、出生缺陷与相关妇儿疾病教育部重点实验室
^2. 610041武警四川省总队成都医院内科

收稿日期:2016-10-08 修回日期:2016-11-10 出版日期:2016-12-01
通信作者: 王峥

Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration

Yannan Guo¹, Hua Ming², Xiuying Chen¹, Zheng Wang¹^,^†()

^1. Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
^2. Department of Medicine, Chengdu Hospital of Chinese People Armed Police Forces, Chengdu 610041, Sichuan Province, China

Received:2016-10-08 Revised:2016-11-10 Published:2016-12-01
Corresponding author: Zheng Wang
About author:
Corresponding author: Wang Zheng, Email: wangzheng48@126.com

全文 ( ) 下载PDF ( ) 导出引用

引用本文：

郭妍南, 明华, 陈秀英, 王峥. 枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过治疗中的应用[J/OL]. 中华妇幼临床医学杂志(电子版), 2016, 12(06): 726-730.

Yannan Guo, Hua Ming, Xiuying Chen, Zheng Wang. Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2016, 12(06): 726-730.

目的

探讨枸橼酸钠抗凝在脓毒症伴急性肾损伤患儿连续性静脉-静脉血液滤过(CVVH)中的应用。

方法

选择2008年5月至2016年4月，在四川大学华西第二医院住院并拟行CVVH治疗的51例脓毒症伴急性肾损伤患儿为研究对象。对其在CVVH治疗中采用枸橼酸钠抗凝。检测不同观察时间点及滤器前、后活化部分凝血活酶时间(APTT)及血清Ca^2＋浓度。观察本组患儿治疗前、后血肌酐、尿素氮、急性生理与慢性健康(APACHE)Ⅱ评分、滤器凝血情况及治疗不良反应。本研究遵循的程序符合四川大学华西第二医院人体试验委员会所制定的伦理学标准，得到该委员会批准，征得受试对象监护人的知情同意，并与之签署临床研究知情同意书。

结果

①本组患儿治疗前与治疗结束后0.5 h APTT水平比较，差异无统计学意义(t＝－1.06，P>0.05)；治疗2、4、8 h时，患儿滤器后APTT水平均显著高于滤器前，并且差异有统计学意义(t＝－28.30、－7.14、－26.11，P<0.001)。②本组患儿治疗结束后0.5 h血清Ca^2＋浓度较治疗前显著降低，并且差异有统计学意义(t＝4.63，P<0.05)；治疗2、4、8 h时，患儿滤器后血清Ca^2＋浓度显著低于滤器前，差异也有统计学意义(t＝6.00、7.47、13.90，P<0.05)。③治疗后患儿血清肌酐、尿素氮及APACHEⅡ评分均较治疗前明显下降，差异有统计学意义(t＝3.03、4.10、3.16，P<0.05)。④本研究无1例患儿发生3级滤器凝血和治疗不良反应。

结论

枸橼酸抗凝技术在儿童CVVH治疗中能有效发挥抗凝作用，治疗不良反应小，临床使用较安全。

关键词: 抗凝药, 柠檬酸, 肾替代疗法, 活化部分凝血活酶时间, 儿童

Objective

To explore the clinical application of sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration(CVVH).

Methods

From May 2008 to April 2016, a total of 51 children from West China Second University Hospital, Sichuan University, were included into the study. Sodium citrate anticoagulation were used during CVVH. The acitivatedpartial thromboplsatin time (APTT), ionized calcium concentration of before and after filter were measured at different time points.The serum creatinine, urea nitrogen, acute physiology and chronic health evaluation(APACHE)Ⅱ scores, filter clotting and treatment adverse reaction were also observed. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of West China Second University Hospital, Sichuan University.Informed consent was obtained from each participants′parents.

Results

①There was no significant difference between before and 0.5 h after treatment in APTT levels (t=-1.06, P>0.05). The APTT levels of post-filter were prolonged significantly compared with that of pre-filter at 2, 4, 8 h during CRRT(t=-28.30, -7.14, -26.11; P<0.001). ②The ionized calcium at before treatment was higher than at 0.5 h after treatment, and the differece was significant(t=4.63, P<0.05). At 2, 4, 8 h during CRRT, ionized calcium of post-filter were decreased significantly than those of pre-filter(t=6.00, 7.47, 13.90; P<0.05). ③Compared to before treatment, the serum creatinine, urea nitrogen, APACHE Ⅱ scores after treatment were declined significantly (t=3.03, 4.10, 3.16; P<0.05). ④There were no level 3 filter clotting or treatment adverse reactions be observed.

Conclusion

Sodium citrate is clinically effective, safe and less adverse reactions in the anticoagulation of CVVH in children.

Key words: Anticoagulants, Citric acid, Renal replacement therapy, Activated partial thromboplsatin time, Child

表1 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点APTT水平比较(s, ±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	30.7±3.0	30.6±3.5	31.1±3.2
滤器后	51	48.8±4.3	53.4±6.1	52.8±4.2
t值	?	－28.30	－7.14	－26.11
P值	?	<0.001	<0.001	<0.001

表1 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点APTT水平比较(s, ±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	30.7±3.0	30.6±3.5	31.1±3.2
滤器后	51	48.8±4.3	53.4±6.1	52.8±4.2
t值	?	－28.30	－7.14	－26.11
P值	?	<0.001	<0.001	<0.001

表2 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点血清Ca^2＋浓度比较(mmol/L，±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	1.06±0.15	0.97±0.13	1.00±0.07
滤器后	51	0.46±0.08	0.47±0.04	0.44±0.03
t值	?	6.00	7.47	13.90
P值	?	<0.05	<0.05	<0.05

表2 脓毒症伴急性肾损伤患儿CVVH治疗滤器前、后不同观察时间点血清Ca^2＋浓度比较(mmol/L，±s)

采血点	例数	治疗2 h	治疗4 h	治疗8 h
滤器前	51	1.06±0.15	0.97±0.13	1.00±0.07
滤器后	51	0.46±0.08	0.47±0.04	0.44±0.03
t值	?	6.00	7.47	13.90
P值	?	<0.05	<0.05	<0.05

表3 脓毒症伴急性肾损伤患儿CVVH治疗前、后血肌酐、尿素氮及APACHEⅡ评分比较(±s)

观察时间点	例数	肌酐(mol/L)	尿素氮(mmol/L)	APACHE Ⅱ评分(分)
治疗前	51	595.0±124.7	33.9±12.7	17.3±5.0
治疗后	51	415.0±37.9	18.4±5.9	13.5±1.4
t值	?	3.03	4.10	3.16
P值	?	<0.05	<0.05	<0.05

表3 脓毒症伴急性肾损伤患儿CVVH治疗前、后血肌酐、尿素氮及APACHEⅡ评分比较(±s)

观察时间点	例数	肌酐(mol/L)	尿素氮(mmol/L)	APACHE Ⅱ评分(分)
治疗前	51	595.0±124.7	33.9±12.7	17.3±5.0
治疗后	51	415.0±37.9	18.4±5.9	13.5±1.4
t值	?	3.03	4.10	3.16
P值	?	<0.05	<0.05	<0.05

[1]	Khwaja A．KDIGO clinical practice guidelines for acutekidney injury[J]．Nephron Clin Pract，2012，120(4)：c179-c184.
[2]	周莉，米绪华，唐万欣，等. 低分子肝素抗凝、枸橼酸抗凝和无抗凝剂技术在危重病患者实施连续性静脉-静脉血液滤过中的应用[J]. 中国血液净化，2007, 6(10)：566-567.
[3]	王婷立，付平. 枸橼酸抗凝在连续肾脏替代治疗中的应用方法和监测[J]. 中国血液净化，2015, 14(9): 566-568.
[4]	LietJM, Allain-LaunayE, Gaillard-LeRouxB, et al. Regional citrate anticoagulation for pediatric CRRT using integrated citrate software and physiological sodium concentration solutions[J]. Pediatr Nephrol, 2014, 29(9): 1625-1631.
[5]	张延龄．介绍一种评估外科重危病人预后的方法APACHEⅡ评分系统[J]．国外医学：外科学分册，1991，18(3): 136-138.
[6]	何长民，张训，主编．肾脏替代治疗学[M]. 上海：上海科学技术文献出版社，1999: 50.
[7]	HafnerS, StahlW, FelsT, et al. Implementation of continuous renal replacement therapy with regional citrate anticoagulation on a surgical and trauma intensive care unit: impact on clinical and economic aspects-an observational study[J]. J Intensive Care, 2015, 3(1): 35.
[8]	Nurmohamed SA, Jallah BP, Vervloet MG, et al. Continuous venovenous hemofiltration with citrate-buffered replacement solution is safe and efficacious in patients with a bleeding tendency: a prospective observational study[J]. BMC Nephrol, 2013, 14：89.
[9]	Oudemans-van Straaten HM. Citrate anticoagulation for continuous renal replacement therapy in the critically ill[J]. Blood Purif, 2010, 29(2)：191-196.
[10]	Straaten OV. Citrate for continuous renal replacement therapy: safer, better and cheaper[J]. Critical Care, 2014, 18(6)：1-3.
[11]	Hofmann RM, Maloney C, Ward DM, et al. A novel method for regional citrate anticoagulation in continuous venovenous hemofiltration (CVVHF)[J]. Ren Fail, 2002, 24(3)：325-335.
[12]	Gabutti L, Marone C, Colucci G, et al. Citrate anticoagulation in continuous venovenous hemodiafiltration: a metabolic challenge[J]. Intensive Care Med, 2002, 28(10): 1419-1425.
[13]	Stucker F，Ponte B，Tataw J, et al. 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]. Critical Care, 2015, 19(1)：1-9.
[14]	Lee YK, Lee HW, Choi KH, et al. Ability of nafamostat mesilate to prolong filter patency during continuous renal replacement therapy in patients at high risk of bleeding: a randomized controlled study[J]. PLoS One, 2014, 9(10): e108737.
[15]	Calatzis A, Toepfer M, Schramm W, et al. Citrate anticoagulation for extracorporeal circuits: effects on whole blood coagulation activation and clot formation[J]. Nephron, 2001，89(2)：233-236.
[16]	Kutsogiannis DJ, Gibney RT, Stollery D, et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients[J]. Kidney Int, 2005, 67(6)：2361-2367.
[17]	Chadha V, Garg U, Warady BA, et al. Citrate clearance in children receiving continuous venovenous renal replacement therapy[J]. Pediatr Nephrol, 2002, 17(10)：819-824.

[1]	陶宏宇, 叶菁菁, 俞劲, 杨秀珍, 钱晶晶, 徐彬, 徐玮泽, 舒强. 右心声学造影在儿童右向左分流相关疾病中的评估价值[J/OL]. 中华医学超声杂志（电子版）, 2024, 21(10): 959-965.
[2]	刘琴, 刘瀚旻, 谢亮. 基质金属蛋白酶在儿童哮喘发生机制中作用的研究现状[J/OL]. 中华妇幼临床医学杂志(电子版), 2024, 20(05): 564-568.
[3]	向韵, 卢游, 杨凡. 全氟及多氟烷基化合物暴露与儿童肥胖症相关性研究现状[J/OL]. 中华妇幼临床医学杂志(电子版), 2024, 20(05): 569-574.
[4]	姚金含, 王伟娜, 张玉泉. 妊娠相关深静脉血栓形成患者的预后研究现状[J/OL]. 中华妇幼临床医学杂志(电子版), 2024, 20(04): 367-373.
[5]	刘静, 王燕妮, 王继萍. 儿童毛发移植应用前景及病例讨论[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(04): 368-368.
[6]	郑宝英, 黄小兰, 贾楠, 朱春梅. 儿童难治性肺炎支原体肺炎早期预警指标[J/OL]. 中华实验和临床感染病杂志(电子版), 2024, 18(04): 215-221.
[7]	刘冉佳, 崔向丽, 周效竹, 曲伟, 朱志军. 儿童肝移植受者健康相关生存质量评价的荟萃分析[J/OL]. 中华移植杂志(电子版), 2024, 18(05): 302-309.
[8]	丁荷蓓, 王珣, 陈为国. 七氟烷吸入麻醉与异丙酚静脉麻醉在儿童腹股沟斜疝手术中的应用比较[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 570-574.
[9]	中华医学会器官移植学分会, 中华医学会外科学分会外科手术学学组, 中华医学会外科学分会移植学组, 华南劈离式肝移植联盟. 劈离式供肝儿童肝移植中国临床操作指南[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 593-601.
[10]	刘军, 丘文静, 孙方昊, 李松盈, 易述红, 傅斌生, 杨扬, 罗慧. 在体与离体劈离式肝移植在儿童肝移植中的应用比较[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 688-693.
[11]	张佳臣, 宋红欣. 儿童青少年等效球镜屈光度变化与屈光不正进展相关性的临床研究[J/OL]. 中华眼科医学杂志(电子版), 2024, 14(04): 217-222.
[12]	张琛, 秦鸣, 董娟, 陈玉龙. 超声检查对儿童肠扭转缺血性改变的诊断价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 565-568.
[13]	王晓瑜, 郭群英, 牛雅萌, 赵成松. 公立儿童医院促进儿科就医均等化实践探析[J/OL]. 中华临床医师杂志(电子版), 2024, 18(04): 383-387.
[14]	陈晓胜, 何佳, 刘方, 吴蕊, 杨海涛, 樊晓寒. 直立倾斜试验诱发31 秒心脏停搏的植入心脏起搏器儿童一例并文献复习[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 488-494.
[15]	曹亚丽, 高雨萌, 张英谦, 李博, 杜军保, 金红芳. 儿童坐位不耐受的临床进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 510-515.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Sodium citrate anticoagulation in sepsis children with acute kidney injury treated with continuous veno-venous hemofiltration