局部枸橼酸抗凝在血浆吸附及血浆置换治疗严重肝损害中的有效性及安全性  

Safety and efficacy of regional citrate anticoagulation during plasma adsorption plus plasma exchange therapy for patients with severe liver dysfunction

作　　者：杜涛 毕伟红 王婷 付新维 张艳玲 DU Tao;BI Wei-hong;WANG Ting;FU Xin-wei;ZHANG Yan-ling(The Third Hospital of Mianyang,Sichuan Mental Health Center,621000 Mianyang,Sichuan,China)

机构地区：[1]绵阳市第3人民医院·四川省精神卫生中心,四川绵阳621000

出　　处：《临床消化病杂志》2022年第3期193-198,共6页Chinese Journal of Clinical Gastroenterology

摘　　要：[目的]评估严重肝功能损害患者行双重血浆分子吸附及血浆置换时采用枸橼酸抗凝的有效性及安全性。[方法]回顾性分析本院37例接受双重血浆分子吸附系统(DPMAS)及血浆置换(PE)治疗的严重肝功能异常患者的一般资料,治疗前后的实验室指标的变化。[结果]本研究共纳入21例患者(男20例、女1例)接受42次DPMAS+PE治疗,MELD评分平均为26.42。总钙(Catot)与上游离钙(Caion)的比值(Catot/Caion)≥2.5判定为枸橼酸蓄积,18例(42.86%)出现枸橼酸蓄积表现。所有患者均顺利完成治疗,治疗结束后无代谢性酸中毒出现,21.43%患者出现碱中毒(pH>7.5)表现。肝功能损害患者MELD评分≥26.98、INR≥1.91预示着患者有更大可能发生枸橼酸蓄积,敏感度分别是61%、67%,特异性分别是75%、67%。[结论]严重肝功能损害患者行血浆吸附加血浆置换时采用枸橼酸抗凝是可行和安全的,但在治疗过程中需要密切监测患者电解质及代谢情况。对于MELD评分和INR明显升高的患者,需要谨慎选择枸橼酸抗凝治疗。[Objective]To assess the safety and efficacy of regional citracte anticoaqulation(RCA)during double plasma molecular adsorption system(DPMAS)plus plasma adsorption(PE)therapy for patients with severe liver dysfunction.[Methods]A retrospective study was conducted in the Third Hospital of Mianyang.We performed DPMAS plus PE runs by using citrate for regional anticoagulation in patients with severe liver failure.We collected and analyzed basic characteristics and laboratory examination.[Results]Total 42 sessions of DPMAS plus PE therapy were performed in 21 patients with severe liver failure.At admission,the mean MELD score was 26.42.Accumulation of citrate was detected indirectly by total serum calcium/ionized serum calcium(Catot/Caion)ratio≥2.5.This was noted in 18 patients(42.86%).No metabolic acidosis was found in the patients after DPMAS plus PE therapy.In 21.43%of cases,metabolic alkalosis occurred with pH>7.5.MELD score≥26.98 and INR≥1.91 predicted an increase in the Catot/Caion ratio≥2.5 with sensitivity(61%for MELD score,67%for INR)and specificity(75%for MELD score,67%for INR).[Conclusion]Our findings suggest RCA might be safe and effective in patients with severe liver dysfunction receiving plasma adsorption plus PE therapy without dialysis and filtration.However,caution and close monitoring of metabolic disorders are needed because wrong management of RCA can result in serious adverse effects in patients with impaired liver function.To identify patients at risk for citrate accumulation in terms of a Catot/Caion ratio≥2.5,MELD score(threshold≥26.98)and INR(threshold≥1.91)may be useful for risk prediction in clinical practice.Careful monitoring of electrolytes and acid-base status is mandatory to ensure patient safety.

关 键 词：肝功能损害 抗凝 枸橼酸 血浆吸附 血浆置换 

分 类 号：R575.3[医药卫生—消化系统]