最新crrt的局部枸橼酸抗凝(杜斌)

ICU的急性肾脏损伤(AKI)
60%
Failure
40%
35.8%
Injury
Risk
7.60%
20%
11.00%
17.20%
0% Acute Kidney Injury*
Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-1843
急性肾功能衰竭的治疗(n = 646)
100%
80% 68.0%
60%
患者百分比(%)
40%
20% 7.4%
0%
非透析
IHD
16.8% CRRT
7.5% IHD+CRRT
Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2007; 8: 14-22
血液进入体外循环后即加入枸橼酸 血液进入体内前补充游离钙 体外循环对血液进行抗凝, 体内血液正常 通过测定游离钙监测抗凝
肝素抗凝时的滤器中空纤维
Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int
*少尿(< 200 ml/12 hr)和(或)明显的氮质血症(BUN > 84 mg/dL)
Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813-818
急性肾功能衰竭的定义: RIFLE标准
Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure: definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-R212
持续肾脏替代治疗管路寿命
满足治疗要求 降低治疗费用 减少重新安装管路的护理时间
18 – 30 hr
1. Holt AW, Bierer P, Glover P, Plummer JL, Bersten AD. Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2002; 28: 1649-55.
2012CRRT的局部枸橼酸抗 凝(杜斌)
ICU中的急性肾脏功能衰竭*: BEST Kidney
患病率
1738/29269 (5.7%, 95%CI 5.5 – 6.0%)
危险因素
感染性休克(47.5%, 95%CI 45.2 – 49.5%)
住院病死率
60.3% (95%CI 58.0 – 62.6%)
2. Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol 1996; 46(3): 199-205. 3. Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 1996; 19: 100-5. 4. Tan HK, Baldwin I, Bellomo R. Continuous veno-venous haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7.
持续肾脏替代治疗的影响因素
血管通路位置 中心静脉导管: 口径, 管腔设计 血流可靠性 血滤管路设计 透析膜的生物相容性 护理人员的培训及专业技能 抗凝效果
持续肾脏替代的抗凝
血滤滤器与管 路的抗凝作用
全身抗凝 有害作用
持续肾脏替代的抗凝选择
基础疾病 现有抗凝措施 临床经验
国内文献报告的抗凝方法
CRRT时的肝素抗凝
肝素抗凝的优缺点
优点 最常用的抗凝方法 临床方案成熟 半衰期短 过量时鱼精蛋白对抗
缺点 出血危险 APTT与滤器寿命无关 肝素诱导血小板缺乏
(HIT)
枸橼酸抗凝的原理
局部枸橼酸抗凝的原理
凝血过程需要游离钙参与 枸橼酸螯合游离钙, 补充钙离子可以恢复 血库使用枸橼酸保存血液 采用枸橼酸可以在RRT时进行局部抗凝:
ቤተ መጻሕፍቲ ባይዱ
低分子肝素抗凝时的滤器中空纤维
Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int