摘要目的 探讨柠檬酸对行连续性肾脏替代治疗(CRRT)的严重烧伤并发急性肾损伤患者的影响. 方法 回顾性分析笔者科室重症监护病房(ICU)2015年1月-2018年12月收治的符合入选标准的83例大面积烧伤并发急性肾损伤患者的病历资料.根据采用的不同抗凝方法,将患者分为肝素组43例[男25例、女18例,年龄(35.0±2.5)岁]和柠檬酸组40例[男22例、女18例,年龄(37.0±6.6)岁].2组患者入院后均进行常规支持治疗,确诊为急性肾损伤后立即行CRRT治疗,肝素组患者采用低分子肝素抗凝,首次按20 U/kg泵入,每小时增加2.5 ～5.0 U;柠檬酸组患者按150 ～200 mL/h泵入0.02 g/mL柠檬酸抗凝.统计2组患者血滤器使用时间、尿量恢复正常时间、住ICU时间;治疗前及治疗24 h血小板计数、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT),血清肌酐、尿素氮、胱抑素C、降钙素原、C反应蛋白,中性粒细胞、白细胞计数、血糖、天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT),心率、体温、平均动脉压;住院期间出血、低钙血症、代谢性酸中毒、代谢性碱中毒、伤后28 d内死亡情况.对数据行t检验、x2检验. 结果 柠檬酸组患者血滤器使用时间为(28.7 ±3.2)h,明显长于肝素组的(19.4 ±2.6)h,t=14.139,P＜0.01.柠檬酸组患者尿量恢复正常时间及住ICU时间分别为(7.6±0.9)、(9.6±1.3)d,明显短于肝素组的(9.2±1.5)、(11.2±1.8)d,t=5.516、4.697,P＜0.01.2组患者治疗前血小板计数、APTT、PT比较,差异无统计学意义(t=1.235、0.515、1.279,P＞0.05).柠檬酸组患者治疗24 h血小板计数明显高于肝素组(t=10.947,P＜0.01),APTT及PT明显短于肝素组(t=7.069、9.142,P＜0.01).2组患者治疗前血清肌酐、尿素氮、胱抑素C比较,差异无统计学意义(t =1.684、1.878、1.472,P＞0.05),柠檬酸组患者治疗24 h血清肌酐、尿素氮、胱抑素C均明显低于肝素组(t=7.778、9.776、5.117,P＜0.01).2组患者治疗前血清降钙素原、C反应蛋白比较,差异无统计学意义(t=1.413、0.898,P＞0.05),柠檬酸组患者治疗24 h血清降钙素原、C反应蛋白均明显低于肝素组(t=2.635、2.297,P＜0.05).2组患者治疗前中性粒细胞、白细胞计数、血糖、AST、ALT比较,差异无统计学意义(￡=0.555、0.816、0.470、1.896、0.982,P＞0.05);柠檬酸组患者治疗24 h中性粒细胞、白细胞计数、血糖、AST、ALT明显低于肝素组(t=2.054、3.314、7.185、2.151、3.013,P＜0.05或P＜0.01).2组患者治疗前心率、体温及平均动脉压比较,差异无统计学意义(t=1.406、0.474、0.720,P＞0.05);柠檬酸组患者治疗24 h心率、体温及平均动脉压均明显低于肝素组(t=2.307、4.498、2.056,P＜0.05或P＜0.01).柠檬酸组患者住院期间出血发生率明显低于肝素组(x2 =4.949,P＜0.05);2组患者住院期间低钙血症、代谢性酸中毒、代谢性碱中毒发生率及伤后28 d内病死率比较,差异无统计学意义(x2=3.346、0.884、0.297、0.324,P＞0.05). 结论 柠檬酸对行CRRT治疗的大面积烧伤并发急性肾损伤患者的抗凝效果显著,可延长血滤器使用寿命,缩短尿量恢复正常时间及住ICU时间,改善肾功能、炎症及血生化指标,维持内环境稳定,降低出血风险.

abstractsObjective To explore the effects of citric acid on patients with severe burn complicated with acute renal injury treated by continuous renal replacement therapy (CRRT).Methods Medical records of 83 patients with large area of burn complicated with acute renal injury admitted to intensive care unit (ICU) of our department from January 2015 to December 2018 and meeting the inclusion criteria were analyzed retrospectively.The patients were divided into heparin group [n =43,25 males and 18 females,aged (35.0 ± 2.5) years] and citric acid group [n =40,22 males and 18 females,aged (37.0 ± 6.6) years] according to different anticoagulation methods.After admission,routine support treatment and CRRT were performed after being diagnosed with acute renal injury in patients in 2 groups.Patients in heparin group were treated with low molecular weight heparin for anticoagulation with first dosage of 20 U/kg and an increase of 2.5 to 5.0 U per hour,and patients in citric acid group were given citric acid of 0.02 g/mL with dosage of 150 ～200 mL/h for anticoagulation.The use time of blood filter,recovery time of urine volume,and time of staying in ICU,and platelet count,activated partial thromboplastin time (APTT),prothrombin time (PT),and serum creatinine,urea nitrogen,cystatin C,procalcitonin,C-reactive protein,and neutrophil,leukocyte count,blood sugar,aspartate aminotransferase (AST),alanine aminotransferase (ALT),and heart rate,body temperature,and mean arterial pressure before treatment and post treatment hour (PTH) 24 were recorded.Besides,occurrence of hemorrhage,hypocalcemia,metabolic acidosis,metabolic alkalosis,and death within 28 days post injury were recorded.Data were processed with t test and chi-square test.Results The use time of blood filter of patients in citric acid group was (28.7 ± 3.2)h,significantly longer than (19.4 ± 2.6) h in heparin group (t =14.139,P ＜ 0.01).The recovery time of urine volume and time of staying in ICU of patients in citric acid group were respectively (7.6 ± 0.9) and (9.6 ± 1.3) d,significantly shorter than (9.2 ± 1.5) and (11.2 ± 1.8) d in heparin group (t =5.516,4.697,P ＜ 0.01).Before treatment,there were no statistically significant differences in platelet count,APTT,and PT of patients in 2 groups (t =1.235,0.515,1.279,P ＞0.05).At PTH 24,the platelet count of patients in citric acid group was significantly higher than that in heparin group (t =10.947,P ＜ 0.01),and APTT and PT of patients in citric acid group were significantly shorter than those in heparin group (t =7.069,9.142,P ＜ 0.01).Before treatment,there were no statistically significant differences in serum creatinine,urea nitrogen,and cystatin C of patients in 2 groups (t =1.684,1.878,1.472,P ＞ 0.05).At PTH 24,the serum creatinine,urea nitrogen,and cystatin C of patients in citric acid group were significantly lower than those in heparin group (t =7.778,9.776,5.117,P ＜ 0.01).Before treatment,there were no statistically significant differences in serum procalcitonin and C-reactive protein of patients in 2 groups (t =1.413,0.898,P ＞ 0.05).At PTH 24,the serum procalcitonin and C-reactive protein of patients in citric acid group were significantly lower than those in heparin group (t =2.635,2.297,P ＜ 0.05).Before treatment,there were no statistically significant differences in neutrophil,leukocyte count,blood sugar,AST,and ALT of patients in 2 groups(t =0.555,0.816,0.470,1.896,0.982,P ＞0.05).At PTH 24,the neutrophil,leukocyte count,blood sugar,AST,and ALT of patients in citric acid group were significantly lower than those in heparin group(t =2.054,3.314,7.185,2.151,3.013,P ＜0.05 orP ＜ 0.01).Before treatment,there were no statistically significant differences in heart rate,body temperature,and mean arterial pressure of patients in 2 groups (t =1.406,0.474,0.720,P ＞ 0.05).At PTH 24,the heart rate,body temperature,and mean arterial pressure of patients in citric acid group were significantly lower than those inheparin group(t =2.307,4.498,2.056,P ＜0.05 orP ＜0.01).The incidence of hemorrhage of patients in citric acid group while in hospital was significantly lower than that in heparin group (x2 =4.949,P ＜ 0.05).There were no statistically significant differences in incidence of hypocalcemia,metabolic acidosis,metabolic alkalosis,and death rate within 28 days post injury of patients in 2 groups while in hospital (x2 =3.346,0.884,0.297,0.324,P ＞ 0.05).Conclusions Citric acid has significant anticoagulant effect on patients with large area of burn complicated with acute renal injury treated by CRRT,which can prolong the use time of the blood filter,shorten the recovery time of urine volume and time of staying in ICU,improve renal function indexes,blood biochemical indexes,and inflammation indexes,maintain the stability of internal environment,and reduce the risk of hemorrhage.