局部枸橼酸联合小剂量低分子肝素抗凝在连续性肾脏替代治疗中的应用  

Regional citrate plus low dose of low molecular weight heparins in continuous veno-venous hemofiltration

作　　者：张凯悦[1] 徐斌[2] 吴丛业[2] 刘志红[2] 季大玺[2] 龚德华[2] 

机构地区：[1]南京大学临床医学院 [2]南京军区南京总医院 全军肾脏病研究所,南京210016

出　　处：《肾脏病与透析肾移植杂志》2012年第4期311-316,共6页Chinese Journal of Nephrology,Dialysis & Transplantation

基　　金：国家自然科学基金面上项目(81170708)

摘　　要：目的:通过单中心随机、对照、前瞻性临床研究比较局部枸橼酸、低分子肝素(LMWH)、局部枸橼酸联合小剂量LMWH三种抗凝方法在连续性静脉-静脉血液滤过(CVVH)中的疗效及安全性。方法:将2010年11月至2011年9月期间南京军区南京总医院住院行CVVH(顶计≥30h)、无抗凝禁忌的危重症患者根据抗凝方式不同,随机分成局部枸橼酸组(A组)、LMWH组(B组)、局部枸橼酸联合小剂量LMWH组(C组)。滤器使用时间≤8h、临床需要或明显抗凝相关并发症出现时需更换抗凝方案。主要观察终点为滤器使用寿命,同时观察血红蛋白(Hb)、血小板计数(PLT)、凝血指标、治疗前后血气的变化及出血发生情况。结果:共入组57例患者,其中A及C组各有2例未完成观察,余53例纳入分析,其中男性36例(67.9%),女性17例(32.1%),A、B及C组各有15、19及19例;3组滤器使用寿命分别是(21.22±13.49)h,(25.1±23.97)h,(40.35±30.88)h(P<0.01)。治疗过程中共8例患者因抗凝效果不满意更改抗凝方式,其中A组及B组各3例(20%,15.8%)改为C组即枸橼酸联合小剂量LMWH抗凝(P>0.05),C组2例(10.5%)增加LMWH剂量;7例因血气分析结果异常更改抗凝方式,分别为A组3例(20%)、C组4例(21.1%),均停用枸橼酸抗凝(P>0.05),改为碳酸氢盐置换液;4例因出血原因更改抗凝方式的患者均在B组(21%)(P<0.05)。观察过程中A、B、C三组出现Hb、PLT下降达30%以上(三组间P>0.05)。出血观察:仅B组2例(10.5%)(P>0.05)患者引流液观察到出血。三组患者CVVH的治疗时间、住院天数、ICU时间、放弃或死亡的比例均无统计学差异(P>0.05)。结论:枸橼酸联合小剂量LMWH抗凝与单用枸橼酸和LMWH抗凝比较,能显著延长滤器使用寿命,而出血相关不良反应并无明显增加。Objective ： To compare the safety and efficacy of regional citrate plus low dose of low molecular weight heparins （LMWH） with only regional citrate or normal dose of, LMWH for different anticoagulation methods in patients with continuous veno-venuous hemofiltration （CVVH）. Methodology：Fifty seven critically ill patients who requiring CVVH without anticoagulation contraindications were enrolled in this study. They were randomly divided into 3 groups adopting different anticoagulation protocols as following： regional citrate anticoagulation in group A, systemic LMWH in group B [ loading dose of LMWH 40 IU/kg, maintenance dose 4 IU/（kg-h） ] , and regional citrate plus low dose of LMWH in group C [ loading dose 20 IU/kg, maintenance dose 2 IU/（ kg. h ） ]. The primary outcome was the filter survival time, and the secondary outcome was the change of hemoglobin （Hb）, platelet counts （PLT） , and anticoagulation-related side effects. Results：Fifty-three patients completed the study and entered into data analysis, 15 in group A, 19 in group B and 19 in group C. The mean APACHEII scores in each group were 16. 2 ±3.65,17.11±3.5 and 17. 01 ±4. 79,respectively （P 〉 0. 05 ）. The filter survival time were （ 21.2± 3.48 ） h in group A, （ 25.1 ± 5.50 ） h in group B, and（ 40. 4 ± 7. 08 ） h in group C （P 〈0. 01 ）. There were 3 patients in each group of A （20%） and B （ 15.8% ） switching to the anticoagulation protocol of group C due to filter life span less than 8 hrs,4 patients in group B （21%） switching to group C due to bleeding,3 patients in group A （20%） and 4 patients in group C （21.1%） switching to group B due to citrate related complications. The percentage of patients with reduction of Hb and platelet counts levels was more than 30%, while no differences was found among 3 groups （P 〉 0. 05 ）. There were no differences in the CVVH duration, hospital days and ICU days and giving up or death rates between 3 groups. Conclusion ： Compared wit

关 键 词：连续性肾脏替代治疗 枸橼酸 低分子肝素 有效性 安全性 

分 类 号：R459.5[医药卫生—治疗学]