Clinical Observation Of Individualized Regional Citrate Anticoagulation In Hemodialysis

Objective 1.To observe the application effect of different regional citrate anticoagulation（RCA）regimens in maintenance hemodialysis（MHD）patients with high risk of bleeding.2.To simplify the treatment process and improve the effectiveness and safety of hemodialysis by exploring the individualized treatment plan of RCA technology in MHD patients with high risk of bleeding.Methods From January 2021 to December 2021,hospitalized patients with active bleeding or high-risk bleeding tendency in maintenance hemodialysis in the hemodialysis center of our hospital were randomly divided into group A:Two-stage RCA（TS-RCA）and group B:Simplified RCA（S-RCA）.In group A,the infusion tube was connected before the filter at the beginning of extracorporeal circuit（ECC）（before the blood pump）and after the filter（at the venous pot）,and 4%sodium citrate was continuously pumped through the microinjection pump.In group B,4%sodium citrate was continuously pumped before the filter at the beginning of ECC pipeline until the end of dialysis,and sodium citrate was not added to the venous pot.The dialysis solution containing Ca²⁺（1.25mmol/L）was used in both groups.Calcium was not supplied in both groups.After each dialysis treatment,the coagulation degree of filter and venous kettle was examined,and the infusion rate of sodium citrate at the next dialysis was adjusted according to the coagulation condition.The changes of laboratory parameters before and after hemodialysis were monitored,and the parameters during each hemodialysis（HD）treatment were compared and analyzed to evaluate the adequacy of single dialysis and record adverse events.Each patient was selected to obtain a more appropriate sodium citrate anticoagulation scheme by adjusting the infusion rate of sodium citrate.The in vitro citrate concentrations of the two groups were calculated according to the total sodium citrate infusion rate and the specific blood flow rate,respectively.The relationship between the in vitro citrate concentration and the weight of the patient and the calcium ion in the blood gas before dialysis was further analyzed,and the individualized sodium citrate dosage formula was proposed.For the TS-RCA scheme group,the anticoagulation at different ratios was observed according to the infusion rates of sodium citrate before and after each regulator.Results 48 patients were finally included in the RCA scheme,of which 28 patients in group A received 110 dialysis,and 20 patients in group B received 75 dialysis.There was no significant difference in gender,age,BMI,biochemical,electrolyte,blood routine and coagulation function between the 48 patients treated with sodium citrate anticoagulation（P>0.05）.The effective rate of filter anticoagulation in group A was lower than that in group B（P<0.05）.The effective rate of anticoagulation in group A was higher than that in group B（P<0.05）.The dialysis time compliance rate in group A was higher than that in group B（P<0.05）.The solute clearance index（KT/V）and urea clearance rate（URR）in group A were higher than those in group B（P<0.05）.There was no difference in serum total calcium,sodium ion and PH between the two groups after dialysis（P>0.05）.The serum total calcium,sodium ion and PH of the two groups after dialysis were higher than those before dialysis（P<0.05）.The venous pressure and transmembrane pressure in group B were higher than those in group A at 2–4 h after dialysis（P<0.05）.There was no significant difference in the citric acid pump speed between the two groups（P>0.05）,and the in vitro citrate concentration under this scheme was calculated,and there was no significant difference between the two groups（P>0.05）.Two groups were determined in vitro citrate concentration and serum calcium ion of patients before dialysis linear relationship:A group:in vitro citrate concentration=0.120+2.798×X（R²=0.835,P<0.01）,B group:in vitro citrate concentration=1.068+2.082×X（R²=0.784,P<0.001）,two groups after integration:in vitro citrate concentration=0.788+2.239×X（R²=0.631,P<0.001）（among them,X is calcium ion concentration in blood gas before dialysis）.Pearson correlation analysis showed that the correlation coefficient between in vitro citric acid concentration and patient weight in group A was r=0.147（P=0.455）,and that between in vitro citric acid concentration and patient weight in group B was r=-0.235（P=0.319）.In the appropriate citrate anticoagulation scheme selected by each patient in group A,the proportion of sodium citrate infusion speed before and after the device fluctuated between4.5:1 and 6.5:1.Conclusion 1.Compared with S-RCA scheme,TS-RCA scheme is better in the overall anticoagulant effect of ECC pipeline,dialysis time compliance rate and dialysis adequacy.TS-RCA scheme is recommended in clinical practice.2.In RCA-HD treatment,the infusion rate of 4%sodium citrate can be calculated by individualized TS-RCA scheme,and the formula is:4%sodium citrate infusion rate m L/h=（0.788+2.239×pre-dialysis blood gas calcium concentration mmol/L）×blood flow rate ml/min×60/136.This method avoids frequent blood sampling test and the operation process of adjusting the infusion rate of sodium citrate during dialysis,and reduces the adverse reactions caused by excessive or insufficient citric acid.3.When TS-RCA was treated with HD,the ratio of 4%sodium citrate infusion speed before and after the device fluctuated between 4.5:1 and 6.5:1,showing good anticoagulant effect.The individualized two-stage local citrate anticoagulation scheme is safe,effective and easy to implement.