上一篇提到,透析液鈣離子(Ca)的建議濃度約在Ca=2.5-3.0 meq/L,而或許2.5 meq/L(以下關於濃度的敘述,都是指透析液鈣離子濃度)是目前最接近的好答案,但是應該視患者之情況來做出調整,而非一體適用。
這些建議確實留下了一堆問號,或許2013年的這篇研究,能夠讓未來的透析治療更精緻化。
先看看人家大多使用哪種透析液吧!從圖中可看得出來,75%的患者,都使用2.5 meq/L的透析液。
這篇研究結果指出,使用 2.0 meq/L濃度以下的透析液、或患者血中校正後鈣離子濃度較高,都會增加突發性心臟停止(sudden cardiac arrest)的機會。事實上,這篇研究的亮點是,透析液的鈣離子,與血液中的鈣離子,若濃度差異太大,也會增加突發性心臟停止的危險性,濃度差異每增加 1 meq/L,危險性變為1.4倍。[OR: 1.40 (95% CI: 1.10–1.80) p= 0.002 ]
這篇研究令人恍然大悟啊。
雖然透析是在有限的時間內,矯正身體裡多餘的水分與毒素廢物,但是我們都知道,要如何讓患者洗的平穩舒服,其實大方向很明確,就是讓患者在透析過程中,體內的變化盡可能越小越好,不管是毒素的變化、或水分的變化(請參考:脫水速度有沒有上限?)。看起來,鈣離子的變化幅度是否太大,也是需要注意的。
而透析液鈣離子濃度,也是有個下限的,如果用濃度小於 2.0 meq/L的透析液,突發性心臟停止的危險性,將變為兩倍。[OR: 2.00 (95% CI: 1.40–2.90) p<0.001 ]。仔細看內文,那些使用2.0 meq/L的患者,他們血中鈣離子濃度都超過 10 mg/dL,這表示,如果為了降血鈣,而選用2.0 meq/L的透析液,反而會使得血液與透析液的鈣離子濃度差異太大,容易導致危險。
那麼,臨床醫師如果真的遇到血鈣很高,又想要在透析的時候,幫患者多降一點鈣離子,選用2.5 meq/L的透析液,到底能夠洗出多少鈣呢?在後續的雜誌編輯討論中,也提到另一篇研究,能夠解答這個問題,這篇研究提到,當患者的PTH <300 pg/ml時,使用2.5 meq/L的透析液,可以透析出347 mg (± 605)的鈣,而如果是PTH>300 pg/ml者,則可以透析出 626 mg (± 487) 的鈣。
因此,本篇重點結錄:
1. 使用 2.5 meq/L的透析液,確實能夠幫助身體除去多餘的鈣離子,而又不會增加危險性。
2. 絕大部分的患者,都是使用 2.5 meq/L的透析液的,這是為了不讓鈣離子累積在身體中,為了血管的健康。
請與照顧您的醫師,討論透析液鈣離子濃度,盡可能讓身體減少鈣離子的負擔吧!
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