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摘要：
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摘要： 目的 探讨肝衰竭合并急性肾损伤（acute kidney injury，AKI）患者接受局部枸橼酸抗
凝的持续肾脏替代治疗（regional citrate anticoagulation-continuous renal replacement therapy，RCACRRT）中发生代谢不良反应的危险因素。方法 回顾性收集2015年1月至2020年12月于首都医
科大学附属北京地坛医院住院并首次接受RCA-CRRT的肝衰竭合并AKI患者共101例。根据
RCA-CRRT持续12 h、24 h、48 h是否发生酸碱紊乱和枸橼酸蓄积分为发生组和未发生组，比
较两组患者实验室指标（丙氨酸氨基转移酶、总胆红素、凝血酶原活动度、白蛋白等）、
相关临床评分（SOFA评分、MELD评分）、枸橼酸用量、CRRT治疗剂量，采用Logistic回
归分析患者发生酸碱紊乱和枸橼酸蓄积的危险因素。采用受试者工作特征（receiver operator
characteristic，ROC）曲线评价各因素对发生不良反应的预测效能。结果 CRRT持续12 h、
24 h、48 h，酸碱紊乱发生率分别为44.6%（45/101）、47.5%（28/59）和52.0%（13/25）；枸
橼酸蓄积发生率分别为31.7%（32/101）、38.9%（23/59）和52.0%（13/25）。多因素Logistic
回归分析表明，枸橼酸用量（12 h：OR = 1.231，95%CI：1.117～1.335，P ＜ 0.001；24 h：
OR = 1.117，95%CI：1.048～1.189，P ＜ 0.001）是RCA-CRRT治疗12 h和24 h发生酸碱紊乱的
独立危险因素。枸橼酸用量（12 h：OR = 1.694，95%CI：1.325～2.165，P ＜ 0.001；24 h：
OR = 1.149，95%CI：1.020～1.294，P = 0.022）和MELD评分（12 h：OR = 1.159，95%CI：
1.057～1.272，P ＜ 0.002；24 h：OR = 1.805，95%CI：1.229～2.651，P = 0.003）是RCA-CRRT
12 h和24 h发生枸橼酸蓄积的独立危险因素。MELD评分（OR = 1.365，95%CI：1.013～1.839，
P = 0.041）是RCA-CRRT 48 h发生枸橼酸蓄积的独立危险因素。枸橼酸用量预测CRRT 12 h和
24 h发生酸碱紊乱的ROC曲线下面积分别为0.788和0.749。枸橼酸用量预测CRRT 12 h和24 h
发生枸橼酸蓄积的ROC曲线下面积分别为0.681和0.748，MELD评分预测CRRT 12 h、24 h和
48 h发生枸橼酸蓄积的ROC曲线下面积分别为0.940和0.954、0.849。结论 肝衰竭合并急性肾
损伤行RCA-CRRT治疗期间，酸碱紊乱和枸橼酸蓄积的发生率随着CRRT时间延长逐渐升高
（CRRT ＜ 48 h）；MELD评分和枸橼酸用量均可较好地预测不良反应发生，对于MELD评分
和枸橼酸用量较高患者应注意预防酸碱紊乱和枸橼酸蓄积的发生。
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Abstract: Objective To investigate the risk factors of adverse metabolic reactions in patients with liver
failure complicated with acute kidney injury (AKI) undergoing regional citrate anticoagulation-continuous
renal replacement therapy (RCA-CRRT). Methods A total of 101 liver failure patients with AKI treated by
RCA-CRRT in Beijing Ditan Hospital, Capital Medical University from January 2015 to December 2020
were collected. Patients were divided into occurrence group and control group according to the occurrence
of acid-base disorder and citrate accumulation during RCA-CRRT (12 h, 24 h, 48 h). The laboratory
indexes (alanine aminotransferase, total bilirubin, prothrombin time activity, albumin, etc.), related clinical
score (SOFA score, MELD score), citrate dosage and CRRT dose were compared between the two groups.
Logistic regression analysis was used to analyze the risk factors of the disorder and citrate accumulation.
Receiver operator characteristic (ROC) curve was used to evaluate the predictive value of risk factors
on the adverse metabolic reactions. Results The incidence of acid-base disorder were 44.6% (45/101),
47.5% (28/59) and 52.0% (13/25) and the incidence of citrate accumulation were 31.7% (32/101), 38.9%
(23/59) and 52.0% (13/25), respectively, during CRRT lasted for 12 h, 24 h and 48 h. Multivariate Logistic
regression analysis showed that the dosages of citrate (12 h: OR = 1.231, 95%CI: 1.117～1.335, P＜ 0.001;
24 h: OR = 1.117, 95%CI: 1.048～1.189, P ＜ 0.001) were independent risk factors of acid-base disorder
with RCA-CRRT lasted for 12 h and 24 h. The dosages of citrate (12 h: OR = 1.694, 95%CI: 1.325～2.165,
P ＜ 0.001; 24 h: OR = 1.149, 95%CI: 1.020～1.294, P = 0.022) and MELD score (12 h: OR = 1.159,
95%CI: 1.057～1.272, P＜ 0.002; 24 h: OR = 1.805, 95%CI: 1.229～2.651, P = 0.003) were independent
risk factors of citrate accumulation with RCA-CRRT lasted for 12 h and 24 h. MELD score (OR = 1.365,
95%CI: 1.013～1.839, P = 0.041) was an independent risk factor of citrate accumulation with RCACRRT lasted for 48 h. The area under the ROC curve of citrate dosage predicting acid-base disturbance
with CRRT 12 h and 24 h were 0.788 and 0.749, respectively. The area under the ROC curve of citrate
dosage predicting citrate accumulation with CRRT 12 h and 24 h were 0.681 and 0.748, respectively. The
area under the ROC curve of MELD score predicting citrate accumulation with CRRT 12 h, 24 h and
48 h were 0.940, 0.954 and 0.849, respectively. Conclusions During RCA-CRRT, the incidence of acidbase disturbance and citrate accumulation increased with the prolongation of CRRT (CRRT ＜ 48 h). Both
MELD score and citrate dosage can better predict the occurrence of adverse reactions. Patients with high
MELD score and large dosages of citrate should be focused in case of the occurrence of acid-base disorder
and citrate accumulation.
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