阿加曲班抗凝法在伴有血小板减少的脓毒血症患者行连续性肾脏替代治疗中的应用

Argatroban anticoagulation therapy in sepsis patients with thrombocytopenia receiving continuous renal replacement therapy

目的 探讨阿加曲班抗凝法在伴有血小板减少的脓毒血症患者行连续性肾脏替代治疗（CRRT）治疗中的抗凝效果以及安全性.方法 2011 年1 月至2014 年12 月期间在上海市交通大学附属第六人民医院行CRRT 治疗的脓毒血症患者共192 例,113 例患者在CRRT 基线期即出现血小板减少,其中53 例患者采用阿加曲班作为CRRT 抗凝方式,阿加曲班抗凝方法为首剂100 μg/kg,追加剂量为0.3～0.6 μg·kg^-1·min^-1.48 例采用无抗凝剂治疗,另有12 例采用低分子肝素或普通肝素加鱼精蛋白治疗,比较各组的抗凝效果以及安全性,有完整资料且连续CRRT 治疗大于3 d 患者入选.结果 低分子肝素或普通肝素组因例数过少,未予纳入.共纳入阿加曲班组41 例,其中男27 例,女14 例,平均年龄（58.4±18.26）岁,平均APACHEⅡ评分（30.55±6.69）分,无抗凝剂组38 例,其中男28 例,女10 例,平均年龄（56.55±17.56）岁,平均APACHEⅡ评分为（32.41±6.58）分.阿加曲班组基线期血小板计数为（73.71±18.71）3109/L,治疗第3 天血小板计数为（70.02±17.42）3109/L,治疗前后差异无统计学意义（P〉0.05）.无抗凝剂组基线期血小板计数为（76.74±15.46）3109/L,治疗第3 天血小板计数为（68.97±18.14）3109/L,治疗后血小板明显减少,差异具有统计学意义（P〈0.05）.阿加曲班组活化部分凝血酶时间（APTT）和凝血酶原时间（PT）在治疗前后无统计学差异（P〉0.05）,而D-二聚体下降.阿加曲班组均顺利完成每次CRRT 治疗,血滤器及管路在治疗后无明显凝血情况,无明显出血并发症及其他不良反应,而无抗凝剂组滤器及管路Ⅲ级凝血的发生率达到了14.7%.结论 在伴有血小板减少的脓毒血症患者行CRRT 治疗中采用阿加曲班抗凝方法安全有效.

Objective To evaluate the efficacy and safety of argatroban anticoagulation therapy in sepsis patients with thrombocytopenia receiving continuous renal replacement therapy(CRRT). Methods In this retrospective study, we screened all sepsis patients receiving continuous renal replacement therapy(CRRT) at Shanghai Jiaotong University Affiliated Sixth People‘s Hospital from January 2011 to December 2014. Before CRRT, there were 113 sepsis patients were diagnosed thrombocytopenia. Fifty-three patients with thrombocytopenia were treated with argatroban, they received argatroban at a dose of 100 μg/kg as a bolus injection followed by a continuous infusion of 0.3-0.6 μg2kg-12min-1. Forty-eight patients were treated with no anticoagulant. Another 12 cases were treated with low molecular weight heparin or unfractionated heparin plus protamine, anticoagulant effect and safety were compared, patients with complete information and continuous CRRT treatment more than 3 days were enrolled. Results Forty-one patients with complete data were included in the final analysis in the argatroban group, there were 27 males and 14 females, with a mean age of(58.4±18.26) years old. The mean APACHEⅡ score was 30.55±6.69. Thirty-eight patients with complete data were included in no anticoagulant group, there were 28 males and 10 females, with a mean age of(56.55±17.56) years old. The mean APACHEⅡ score was 32.41±6.58. In argatroban group, on the first day of CRRT, baseline platelet count was(73.71±18.71)×109/L, compared with the third day [(70.02±17.42)×109/L], there was no significantly difference(P>0.05). In no anticoagulant group, on the first day of CRRT, baseline platelet count was(76.74±15.46)×109/L, compared with the third day [(68.97±18.14)×109/L], there was significantly difference(P<0.05). Patients anticoagulant function were examined before and after CRRT. There was also no significantly difference in the activated partial thromboplastin time(APTT) and prothrombin time(PT)(P>0.05). In argatroban group, all treatments completed successfully. No significant coagulation was found in dialyzers. No major bleeding episodes and serious side effects were found. Conclusion In sepsis patients with thrombocytopenia, argatroban anticoagulation therapy in CRRT is effective and safe.