Clinical review: anticoagulation for continuous renal replacement therapy--heparin or citrate?
Clinical review: anticoagulation for continuous renal replacement therapy--heparin or citrate?
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DOI：
10.1186/cc9358
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发表时间：
2011-01-24
期刊：
影响因子：
--
通讯作者：
Bellomo R
中科院分区：
文献类型：
--
作者：
Oudemans-van Straaten HM;Kellum JA;Bellomo R
肝素是连续性肾脏替代治疗中最常用的抗凝剂。然而，越来越多的证据质疑其安全性，特别是在危重病人中。肝素主要通过与抗凝血酶结合而发挥抗凝作用。然而，肝素也与许多其他蛋白质和细胞结合，从而影响其有效性和安全性。由于抗凝血酶的消耗和降解，以及肝素与急性期蛋白、凋亡和坏死细胞的结合，危重病赋予肝素抗性。肝素的非特异性结合进一步导致对炎症途径、微循环和死细胞的吞噬清除的不可预测的干扰，对脓毒症和全身性炎症患者可能产生有害后果。柠檬酸盐局部抗凝不会增加患者的出血风险。柠檬酸盐的受益还包括更长或相似的回路寿命，以及可能更好的患者和肾脏存活率。这需要在更大规模的随机对照多中心试验中证实。柠檬酸盐的使用可能与较少的炎症有关，并具有有用的生物能量意义。然而，柠檬酸盐使用不当会导致代谢紊乱。只有在风险得到良好控制的情况下，才能充分发挥柠檬酸盐的优势。这些观察结果表明柠檬酸盐的作用更大。
Heparin is the most commonly prescribed anticoagulant for continuous renal replacement therapy. There is, however, increasing evidence questioning its safety, particularly in the critically ill. Heparin mainly confers its anticoagulant effect by binding to antithrombin. Heparin binds to numerous other proteins and cells as well, however, compromising its efficacy and safety. Owing to antithrombin consumption and degradation, and to the binding of heparin to acute phase proteins, and to apoptotic and necrotic cells, critical illness confers heparin resistance. The nonspecific binding of heparin further leads to an unpredictable interference with inflammation pathways, microcirculation and phagocytotic clearance of dead cells, with possible deleterious consequences for patients with sepsis and systemic inflammation. Regional anticoagulation with citrate does not increase the patient's risk of bleeding. The benefits of citrate further include a longer or similar circuit life, and possibly better patient and kidney survival. This needs to be confirmed in larger randomized controlled multicenter trials. The use of citrate might be associated with less inflammation and has useful bio-energetic implications. Citrate can, however, with inadequate use cause metabolic derangements. Full advantages of citrate can only be realized if its risks are well controlled. These observations suggest a greater role for citrate.
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