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Zitratantikoagulation in der akuten Nierenersatztherapie

Methode der Wahl

Citrate anticoagulation in acute renal replacement therapy

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Zusammenfassung

Hintergrund

Antikoagulation ist Voraussetzung für eine effektive kontinuierliche Nierenersatztherapie (CRRT). Vorzeitige Thrombosierung des Extrakorporalsystems führt zu Therapieunterbrechungen, erhöht die Behandlungskosten und verursacht relevante Blutverluste.

Regionale Antikoagulation

Die regionale Antikoagulation mit Zitrat (RZA) bewirkt eine zuverlässige Gerinnungshemmung und ist im Hinblick auf Filterstandzeiten dem Heparin eindeutig überlegen. Ein Blutungsrisiko kann vom Wirkprinzip her ausgeschlossen werden. Die RZA gilt aufgrund der technischen Entwicklung als sicher und wird mittlerweile als neuer Standard bei der CRRT angesehen. Bioinkompatibilitätsreaktionen, wie Leukozytendegranulierung und Komplementaktivierung, sind unter RZA abgemildert.

Diskussion

Ein möglicher Überlebensvorteil durch RZA ließ sich durch neuere Studiendaten nicht bestätigen. Bei schwerer Leberinsuffizienz und Laktatacidose stößt die RZA an ihre Grenzen. Die trotz Kalziumsubstitution oft negative Kalziumbilanz bei CRRT mit RZA kann bei längeren Behandlungszeiten einen sekundären Hyperparathyreoidismus und im Extremfall eine Osteomalazie hervorrufen. Auch für die intermittierende Dialyse ist die RZA eine wertvolle Option.

Abstract

Background

Anticoagulation is prerequisite for efficient continuous renal replacement therapy (CRRT). Premature clotting of the extracorporeal system leads to therapy interruptions, is costly, and causes relevant blood losses.

Regional anticoagulation

Regional citrate anticoagulation (RCA) achieves reliable coagulation inhibition and is clearly superior to heparin with regard to filter survival time. Due to its mode of action, a bleeding risk can be excluded. RCA with the commercial machine solutions is safe and has been promoted as the new standard anticoagulant for CRRT. Bioincompatibility reactions like leukocyte degranulation and complement system activation are ameliorated under RCA.

Discussion

An assumed survival advantage of RCA could not be confirmed. In case of severe liver insufficiency and lactic acidosis, RCA can lead to metabolic complications. Despite calcium supplementation, the calcium net balance of RCA is often negative. Long treatment durations can therefore cause secondary hyperparathyroidism and in extreme cases osteomalacia. RCA is also a valuable option in intermittent hemodialysis.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. R.D. Frank gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Klinik für Innere Medizin, St.-Antonius-Hospital Eschweiler, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland

    R.D. Frank

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Frank, R. Zitratantikoagulation in der akuten Nierenersatztherapie. Med Klin Intensivmed Notfmed 109, 336–341 (2014). https://doi.org/10.1007/s00063-013-0339-7

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