慢加急性肝衰竭: 东西方诊断和预后的差异

Application of regional citrate anticoagulation during plasma adsorption and plasma exchange for patients with liver failure at high risk of bleeding

AIM

To analyze the feasibility and safety of regional citrate anticoagulation (RCA) during plasma adsorption (PA) plus plasma exchange (PE) therapy for patients with liver failure at high risk of bleeding.

METHODS

This was a retrospective study conducted at the Center of Infectious Diseases, West China Hospital of Sichuan University from October 2016 to July 2017. The clinical data of patients with liver failure at high risk of bleeding who received RCA during PA plus PE therapy were collected. The therapeutic effects, citrate accumulation, electrolytes, and acid-base changes were retrospectively analyzed. Citrate accumulation was defined as the total calcium (Ca_tot) to ionized calcium (Ca_ion) ratio (Ca_tot/Ca_ion) ≥ 2.5.

RESULTS

Of the seven patients included, two survived and five died. Twenty four sessions of RCA for PA plus PE therapy were accomplished. The mean Ca_ionin vitro during PA therapy was 0.28 mmol/L ± 0.09 mmol/L. Citrate accumulation occurred in 45.8% (11/24) of sessions during PA therapy and in all the sessions at the end of PE therapy. Although citrate accumulation still occurred in 41.7% (10/24) of sessions 2 h after PE therapy, it had been decreased obviously when compared with that at the end of PE therapy (P < 0.01) and it was not present by the next morning. No new bleeding occurred and the original bleeding did not deteriorate during and after PA plus PE therapy. The main side effects were alkalosis and transient low level of Ca_ion and high level of Ca_tot.

CONCLUSION

Patients with liver failure still have certain ability to metabolize citrate and tolerate citrate accumulation. RCA may be feasible and safe in the PA plus PE therapy for patients with liver failure.