摘要
目的 探索局部枸橼酸抗凝(regional citrate anticoagulation,RCA)在脓毒症合并高乳酸血症患者连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)中的应用情况,为此类患者的RCA临床应用提供依据.方法 回顾性纳入2021年5月-2023年5月在四川大学华西医院行RCA-CRRT的脓毒症患者.根据CRRT开始前初始乳酸水平将患者分为乳酸正常组(≤2.0 mmol/L)和高乳酸血症组(＞2.0 mmol/L),并对中度高乳酸血症(2 mmol/L＜乳酸水平＜4 mmol/L)和重度高乳酸血症(≥4.0 mmol/L)患者进行亚组分析.进行倾向评分匹配(propensity score matching,PSM),并比较不同组别患者的基线特征和结局指标.结果 共纳入441例患者,乳酸正常组228例,高乳酸血症组213例.PSM前,乳酸正常组与高乳酸血症组的肝衰竭比例、慢性肾脏病比例、平均动脉压、碳酸氢根、总胆红素、肌酐、活化部分凝血活酶时间、国际标准化比值、降钙素原、白细胞介素-6差异有统计学意义(P＜0.05).PSM后,乳酸正常组与高乳酸血症组均为162例患者.两组患者的基线特征差异均无统计学意义(P＞0.05).乳酸正常组与高乳酸血症组的枸橼酸蓄积发生率分别为13.0％和25.9％(P＜0.05).两组的代谢性酸中毒、代谢性碱中毒、高钠血症、滤器凝血事件发生率以及住院期间死亡比例差异均无统计学意义(P＞0.05).Kaplan-Meier生存分析显示,乳酸正常组与高乳酸血症组首个体外循环寿命差异无统计学意义(P＞0.05). 213例高乳酸血症患者中,中度高乳酸血症186例,重度高乳酸血症27例.PSM前,中度与重度高乳酸血症组的男性比例、糖尿病比例、白蛋白水平、国际标准化比值、白细胞介素-6差异均有统计学意义(P＜0.05).PSM后,中度与重度高乳酸1血症组均为22例患者.两组患者的基线特征差异均无统计学意义(P＞0.05).中度高乳酸血症组与重度高乳酸血症组的枸橼酸蓄积发生率分别为18.2％和50.0％(P＜0.05).两组的代谢性酸中毒、代谢性碱中毒、高钠血症、滤器凝血事件发生率以及住院期间死亡比例差异均无统计学意义(P＞0.05).Kaplan-Meier生存分析显示,中度高乳酸血症组与重度高乳酸血症组首个体外循环寿命差异无统计学意义(P＞0.05).结论 RCA用于脓毒症伴高乳酸血症患者的CRRT抗凝时,枸橼酸蓄积发生率较高(尤其是重度高乳酸血症患者),应严密监测.
Abstract
Objective To explore the application of regional citrate anticoagulation(RCA)in continuous renal replacement therapy(CRRT)for patients with sepsis and hyperlactacidemia,and to provide a basis for the clinical application of RCA in such patients.Methods Sepsis patients who underwent RCA-CRRT at West China Hospital of Sichuan University between May 2021 and May 2023 were retrospectively included.Patients were divided into a normal lactate group(≤2.0 mmol/L)and a hyperlactacidemia group(＞2.0 mmol/L)based on their initial lactate levels before CRRT,and subgroup analysis was performed on patients with moderate hyperlactacidemia(2 mmol/L＜lactate level＜4 mmol/L)and severe hyperlactacidemia(≥4.0 mmol/L).Propensity score matching(PSM)was used,and baseline characteristics and outcome measures of different groups of patients were compared.Results A total of 441 patients were included,with 228 in the normal lactate group and 213 in the hyperlactacidemia group.Before PSM,there were statistically significant differences in the proportion of liver failure,proportion of chronic kidney disease,mean arterial pressure,bicarbonate,total bilirubin,creatinine,activated partial thromboplastin time,international standardized ratio,procalcitonin,and interleukin-6 between the normal lactate group and the hyperlactacidemia group(P＜0.05).After PSM,there were 162 patients in both the normal lactate group and the hyperlactacidemia group.There was no statistically significant difference in baseline characteristics between the two groups of patients(P＞0.05).The incidence of citric acid accumulation in the normal lactate group and the hyperlactacidemia group was 13.0％and 25.9％,respectively(P＜0.05).There was no statistically significant difference in the incidence of metabolic acidosis,metabolic alkalosis,hypernatremia,filter coagulation events,or in-hospital mortality between the two groups(P＞0.05).Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the normal lactate group and the hyperlactacidemia group(P＞0.05).Among 213 patients with hyperlactacidemia,186 had moderate hyperlactacidemia and 27 had severe hyperlactacidemia.Before PSM,there were statistically significant differences in the proportion of male,proportion of diabetes,albumin level,international standardized ratio,and interleukin-6 between moderate and severe hyperlactacidemia groups(P＜0.05).After PSM,there were 22 patients in both the moderate and severe hyperlactacidemia groups.There was no statistically significant difference in baseline characteristics between the two groups of patients(P＞0.05).The incidence of citric acid accumulation was 18.2％and 50.0％in the moderate and severe hyperlactacidemia groups,respectively(P＜0.05).There was no statistically significant difference in the incidence of metabolic acidosis,metabolic alkalosis,hypernatremia,filter coagulation events,or in-hospital mortality between the two groups(P＞0.05).Kaplan-Meier survival analysis showed that there was no statistically significant difference in the first extracorporeal circulation lifespan between the moderate and severe hyperlactacidemia groups(P＞0.05).Conclusion When RCA is used for CRRT anticoagulation in patients with sepsis and hyperlactacidemia,the incidence of citric acid accumulation is high(especially in patients with severe hyperlactacidemia),and should be closely monitored.
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