Primerjava citratne in heparinske antikoagulacije med hemodializo s srednje prepustno poliariletersulfon-polivinilpirolidonsko membrano

Malgaj Vrečko, Marija (author), Buturović Ponikvar, Jadranka (mentor)

UVOD: Kljub vedno pogostejši uporabi tako srednje prepustne poliariletersulfonske-polivinilpirolidonske (PES-PVP) membrane kot regionalne citratne antikoagulacije (RCA) še ni opisanih primerov rabe RCA med hemodializo (HD) s to membrano. Namen naše raziskave je bil primerjati biokompatibilnost ter učinkovitost RCA in heparinske antikoagulacije (HA) med HD s PES-PVP membrano. METODE: Izvedli smo randomizirano, navzkrižno študijo na 32 odraslih bolnikih, zdravljenih s kronično HD. Vsak je imel 2 HD s srednje prepustno PES-PVP membrano: eno s HA in eno z RCA. Biokompatibilnost smo ocenili s spremljanjem serumskih koncentracij C3a, C5a (pokazatelja aktivacije komplementnega sistema) in mieloperoksidaze (MPO; pokazatelj aktivacije granulocitov) ter plazemskih koncentracij trombocitnega faktorja 4 (PF4; pokazatelj aktivacije trombocitov) pred HD, po 15 minutah in tik pred koncem HD. Iz omenjenih koncentracij smo s pomočjo linearnega trapeznega pravila izračunali površino pod krivuljo »koncentracija pokazatelja biokompatibilnosti v odvisnosti od časa«. Dodatno smo biokompatibilnost ocenili še s pregledom srednje prepustne PES-PVP membrane po HD z vrstično elektronsko mikroskopijo (SEM – iz ang. scanning electron microscopy). Učinkovitost smo ocenili z izračunom trenutnega in celokupnega očistka ter redukcijskega količnika (RR) ß2-mikroglobulina, fosfata, kreatinina in sečnine. REZULTATI: Po 15 minutah HD s srednje prepustno PES-PVP membrano s HA smo beležili statistično pomemben porast C3a na 135,02 % (p < 0,001), MPO na 204,80 % (p < 0,001) in PF4 na 748,18% (p = 0,02) izhodiščne vrednosti pred HD, po 15 minutah HD s srednje prepustno PES-PVP membrano z RCA ni bilo statistično pomembnega porasta koncentracij. Površine pod krivuljami »koncentracija pokazatelja biokompatibilnosti v odvisnosti od časa« so bile pri RCA statistično pomembno manjše kot pri HA: 1163,0 ± 306,8 proti 1444,1 ± 385,9 µgh/L za C3a (p < 0.001); 78,2 (39,0-131,2) proti 275,1 (136,9-492,9) µgh/L za MPO (p < 0.001) in 100,0 (51,8-196,6) proti 379,4 (295,0-553,0) IUh/mL za PF4 (p = 0.04). Analiza C5a in ocena srednje prepustne PES-PVP membrane s SEM nista pokazali statistično pomembnih razlik med RCA in HA. Pri oceni učinkovitosti so bile statistično pomembne razlike med RCA in HA le pri celokupnem očistku fosfata (130,39 ± 28,34 ml/min pri HA proti 114,04 ± 15,70 mL/min pri RCA; p < 0,001) in trenutnem očistku kreatinina (166,19 (160,37-176,28) mL/min pri RCA proti 162,72 (157,46-172,36) mL/min pri HA; p = 0,04). ZAKLJUČEK: Biokompatibilnost HD s srednje prepustno PES-PVP membrano je pomembno boljša pri uporabi RCA kot pri HA, boljše učinkovitosti RCA v primerjavi s HA pa nismo dokazali.

• Language: Slovenian
• Keywords: hemodializa, antikoagulacija, citrat, heparin
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-149771
• Publication date in RUL: 10.09.2023

Secondary language

• Language: English
• Title: Comparison of citrate and heparin anticoagulation during hemodialysis with medium cut-off polyarylethersulphone-polyvinylpirrolidone membrane

Abstract

BACKGROUND: Although there has been increased use of both medium cut-off membranes (MCO) and regional citrate anticoagulation (RCA) in the recent years, we found no reports of RCA during hemodialysis (HD) with MCO membrane. The aim of this trial was to compare the biocompatibility and efficiency of RCA and anticoagulation with unfractionated heparin (UFH) during HD with MCO membrane. METHODS: A randomized, cross-over study was performed in 32 patients on chronic HD. Each patient had 2 HD with MCO membrane: one with UFH and one with RCA. Biocompatibility was assessed by monitoring serum concentrations of C3a, C5a (markers of complement activation), myeloperoxidase (MPO; marker of granulocyte activation) and plasma concentrations of platelet factor 4 (PF4; marker of platelet activation) before HD, after 15 minutes and just before the end of HD. The area under the biocompatibility marker concentration-time curve (AUC) was calculated from all three concentrations using the linear trapezoidal rule. Biocompatibility was also assessed by visualization of MCO membrane after HD using scanning electron microscopy (SEM). Efficiency was assessed by calculation of overall and instantaneous clearances and reduction ratios (RR) of β2-microglobulin, phosphate, creatinine and urea. RESULTS: The concentrations of C3a, MPO and PF4 rose significantly after 15 minutes of HD with UFH and 135.02% (p < 0.001), 204.80% (p < 0.001) and 748.18% (p = 0.02) of pre-HD values. There were no statistically significant rises of biocompatibility markers after 15 minutes of HD with RCA. The AUC for biocompatibility markers were significantly smaller during HD with RCA in comparison to UFH: 1163.0 ± 306.8 vs. 1444.1 ± 385.9 µgh/L for C3a (p < 0.001); 78.2 (39.0-131.2) vs. 275.1 (136.9-492.9) µgh/L for MPO (p < 0.001) and 100.0 (51.8-196.6) vs. 379.4 (295.0-553.0) IUh/mL for PF4 (p = 0.04). Analysis of C5a concentrations and visualization of MCO membrane after HD using SEM revealed revealed no significant differences between RCA and UFH. Regarding efficiency, there were significant differences in overall clearance of phosphate (130.39 ± 28.34 ml/min during HD with UFH vs. 114.04 ± 15.70 mL/min during HD with RCA; p < 0.001) and instantaneous clearance of creatinine (166.19 (160.37-176.28) mL/min during HD with RCA vs. 162.72 (157.46-172.36) mL/min during HD with UFH; p = 0.04). CONCLUSION: RCA during HD with MCO membrane is superior to UFH in terms of biocompatibility, while we could not prove superior efficiency of RCA in comparison to UFH.

• Keywords: hemodialysis, anticoagulation, citrate, heparin