简化法局部枸橼酸、阿加曲班和无肝素抗凝在高危出血风险血液透析患者中的临床对比观察  

Simplified-regional citrate,argatroban and heparin-free anticoagulation in patients with hemodialysis at high risk of bleeding

作　　者：邱德俊 高卓 李红霞 黄志芳 胡瑞海 伦立德 QIU Dejun;GAO Zhuo;LI Hongxia;HUANG Zhifang;HU Ruihai;LUN Lide(Department of Nephrology,Air Force Medical Center,Beijing 100142,China)

机构地区：[1]空军特色医学中心肾病科,北京100142

出　　处：《空军医学杂志》2020年第6期497-501,505,共6页Medical Journal of Air Force

摘　　要：目的观察简化法局部枸橼酸抗凝(simplified-regional citrate anticoagulation,S-RCA)、小剂量阿加曲班抗凝及无肝素抗凝方法在高危出血风险维持性血液透析(maintenance hemodialysis,MHD)患者中有效性及安全性。方法选取2016年2月—2019年7月空军特色医学中心血液净化中心具有活动性出血或出血倾向的90例MHD患者,随机分为3组,S-RCA组,阿加曲班抗凝组,无肝素抗凝组。观察透析充分性,活化部分凝血活酶时间(activated partial thromboplastin time,APTT),D-二聚体(D-dimer,D-D)及血小板(platelet,PLT)变化,将滤器及静脉壶2级凝血以下视为抗凝有效,计算抗凝有效率,记录不良反应和出血事件。结果 S-RCA组和阿加曲班抗凝组各自均顺利完成30例次透析治疗,其中S-RCA组出现2例口唇麻木,经调整枸橼酸流速和补钙治疗后好转,阿加曲班抗凝组出现2例皮下瘀斑,后自行好转,无肝素抗凝组透析30例次,其中6例次因体外循环凝血较重终止透析,3组均未见明显新发出血或原有出血加重。S-RCA组与阿加曲班抗凝组尿素清除指数(Kt/v)差异无统计学意义(P>0.05),但均高于无肝素抗凝组(P<0.05)。3组透析前后的血肌酐、尿素氮、总钙及pH值差异均有统计学意义(P<0.05),而钠离子差异无统计学意义(P>0.05)。滤器抗凝有效率S-RCA组与阿加曲班抗凝组差异无统计学意义(P>0.05),但均高于无肝素抗凝组(P<0.05),静脉壶抗凝有效率S-RCA组高于其他组(P<0.05)。阿加曲班抗凝组血液透析(hemodialysis,HD)后、HD后1 hAPTT与HD前比较均升高(P<0.05),但HD后1 hAPTT在正常范围内;无肝素抗凝组HD后与HD前比较,D-D升高(P<0.05),PLT降低(P<0.05),S-RCA组HD后游离钙较HD前升高(P<0.05),但在正常范围内。结论 S-RCA和小剂量阿加曲班抗凝对高危出血风险血液透析患者安全、有效,相比于无肝素法,更具优势。Objective To observe the efficacy and safety of simplified-regional citrate anticoagulation(S-RCA), lowdose argatrobananticoagulation and heparin-free anticoagulation in patientswith maintenance hemodialysis(MHD)at high risk ofbleeding. Methods A total of ninety patients with MHD who had active bleeding or bleeding tendency treated between February 2016 and July 2019 in our center were randomly divided into three groups: S-RCA group,argatroban group and heparinfree group. The Kt/v, activated partial thromboplastin time(APTT),D-dimer and platelet count changes pre-and post-HD were observed. The effective rate of anticoagulation was calculated while adverse reactions and bleeding events during dialysis were recorded. Results Thirty cases of dialysis were completed without much trouble in the S-RCA and argatroban groups. There were two cases of lip numbness in the S-RCA group that were improved after adjustment of the citrate flow rate and calcium supplementation. There were also twocases of subcutaneous ecchymosis in the argatroban group. In the heparin-free group, dialysis was completed in thirty cases, but six of them were terminated due tosevere clottingduring extracorporeal circulation, and no obvious new bleeding or aggravation of original bleeding occurred in any of the three groups. There was no significant difference in Kt/v between the S-RCA and argatroban groups(P>0.05), but Kt/v was higher than in the heparin-free group(P<0.05).There were significant differences in SCr, BUN, total Ca, and pH between the three groups before and after dialysis(P<0.05),but there was no significant difference in Na+(P>0.05). There was no significant difference in the anticoagulation efficiency of the filter between the S-RCA and argatroban groups(P>0.05),but they were higher than those of heparin free anticoagulation group(P<0.05). The anticoagulation efficiency of the venous bubble trap was significantly higher in the S-RCA group than in the other groups(P<0.05).APTT was increased after HD in the argatroban group(P<0.05).D-

关 键 词：血液透析 局部枸橼酸抗凝 阿加曲班 无肝素 高危出血风险 

分 类 号：R459.5[医药卫生—治疗学]