摘要目的:探讨局部枸橼酸抗凝的连续性肾脏替代治疗（RCA-CRRT）应用于肝衰竭患者时，发生枸橼酸蓄积的危险因素。方法:回顾性分析2017年1月至2020年6月入住南通市第三人民医院重症监护病房（ICU）行RCA-CRRT肝衰竭患者的临床资料，根据在CRRT过程中是否存在枸橼酸蓄积（血清总钙/游离钙比值≥2.4）将入选患者分为蓄积组和对照组，比较两组患者的年龄、急性生理学与慢性健康状况评分Ⅱ（APACHEⅡ）、平均动脉压（MAP）、去甲肾上腺素（NE）用量、血乳酸（Lac）浓度、肝功能状态、枸橼酸量、滤器使用时间及预后；用非条件逻辑回归分析患者发生枸橼酸蓄积的危险因素。结果:48例行RCA-CRRT的肝衰竭患者中有20例发生枸橼酸蓄积（蓄积组），共进行96次CRRT；其余28例患者未发生枸橼酸蓄积（对照组），共进行106次CRRT。两组年龄和APACHEⅡ评分比较差异无统计学意义。与对照组相比，蓄积组患者MAP较低〔mmHg（1 mmHg＝0.133 kPa）：66.9±13.6比86.4±8.3， P＝0.032〕，NE用量较高（μg/min：16.3±8.4比5.9±2.8， P＝0.015），血Lac水平较高（mmol/L：4.89±1.45比2.98±0.87， P＝0.004），肝功能受损更严重〔总胆红素（TBil，μmol/L）：220.4±45.2比163.4±43.8， P＝0.012；肝功能Child-Pugh评分（分）：12.0±2.5比8.8±1.4， P＝0.029；终末期肝病模型（MELD）评分（分）：31.30±8.22比21.78±6.40， P＝0.041〕，每小时枸橼酸用量（mmol/h：27.4±6.9比19.3±4.9， P＝0.032）及总枸橼酸用量（mmol：3 393±809比1 819±502， P＝0.039）更高。虽然两组患者ICU住院时间、总住院时间及住院费用差异无统计学意义，但蓄积组28 d病死率明显高于对照组（60.0%比28.6%， P＝0.039）。非条件逻辑回归分析显示，MAP〔优势比（ OR）＝2.901，95%可信区间（95% CI）为0.921～19.493， P＝0.019〕、NE用量（ OR＝2.098，95% CI为1.923～12.342， P＝0.002）、血Lac水平（ OR＝5.201，95% CI为3.211～9.433， P＝0.012）、Child-Pugh评分（ OR＝1.843，95% CI为0.437～7.420， P＝0.018）、MELD评分（ OR＝3.012，95% CI为0.384～12.843， P＝0.031）、每小时枸橼酸用量（ OR＝4.254，95% CI为1.734～11.839， P＝0.011）和总枸橼酸用量（ OR＝4.109，95% CI为1.283～18.343， P＝0.001）是发生枸橼酸蓄积的危险因素。 结论:肝功能严重受损患者合并组织低灌注时，应避免使用枸橼酸抗凝或减少枸橼酸用量，以避免发生枸橼酸蓄积。

abstractsObjective:To investigate the risk factors of citrate accumulation in patients with liver failure treated with regional citrate anticoagulated continuous renal replacement therapy (RCA-CRRT).Methods:The clinical data of liver failure patients with RCA-CRRT admitted to department of intensive care unit (ICU) of Nantong Third People's Hospital from January 2017 to June 2020 were retrospectively analyzed. The selected patients were divided into citrate accumulation group and control group according to whether there was citrate accumulation (serum total calcium/free calcium ratio ≥ 2.4) during CRRT. The age, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), mean arterial pressure (MAP), norepinephrine (NE) dose, blood lactic acid (Lac) concentration, liver function status, citrate dose, filter time and prognosis of the patients were compared between the two groups. Unconditional Logistic regression was used to analyze the risk factors for citrate accumulation.Results:Among 48 patients with RCA-CRRT and liver failure, 20 patients had citrate accumulation (accumulation group), and a total of 96 CRRTs were performed; the remaining 28 patients did not have citrate accumulation (control group), a total of 106 CRRTs were performed. There were no significant differences in age and APACHEⅡ score between the two groups. Compared with the control group, the MAP in the accumulation group was lower [mmHg (1 mmHg = 0.133 kPa): 66.9±13.6 vs. 86.4±8.3, P = 0.032], and the dosage of NE (μg/min: 16.3±8.4 vs. 5.9±2.8, P = 0.015) and lactic acid level (mmol/L: 4.89±1.45 vs. 2.98±0.87, P = 0.004) were higher, the damage of liver function was more serious [total bilirubin (TBil, μmol/L): 220.4±45.2 vs. 163.4±43.8, P = 0.012; Child-Pugh score: 12.0±2.5 vs. 8.8±1.4, P = 0.029; model for end-stage liver disease (MELD) score: 31.30±8.22 vs. 21.78±6.40, P = 0.041], hourly citric acid dosage (mmol/h: 27.4±6.9 vs. 19.3±4.9, P = 0.032) and total citric acid dosage (mmol: 3 393±809 vs. 1 819±502, P = 0.039) were higher. Although there were no significant differences in the length of ICU stay, total length of hospitalization stay and cost of hospitalization between the two groups, the 28-day mortality of the accumulation group was higher than that of the control group (60.0% vs. 28.6%, P = 0.039). Unconditional Logistic regression analysis showed that MAP [odds ratio ( OR) = 2.901, 95% confidence interval (95% CI) was 0.921-19.493, P = 0.019], NE dosage ( OR = 2.098, 95% CI was 1.923-12.342, P = 0.002), Lac level ( OR = 5.201, 95% CI was 3.211-9.433, P = 0.012), Child-Pugh score ( OR = 1.843, 95% CI was 0.437-7.420, P = 0.018), MELD score ( OR = 3.012, 95% CI was 0.384-12.843, P = 0.031), hourly citric acid dosage ( OR = 4.254, 95% CI was 1.734-11.839, P = 0.011) and total citric acid dosage ( OR = 4.109, 95% CI was 1.283-18.343, P = 0.001) were risk factors for citrate accumulation. Conclusion:In patients with tissue hypoperfusion and severe liver function damage, citrate anticoagulation should be avoided or the dosage of citric acid should be reduced, in order to avoid citrate accumulation.