血凝酶对异基因造血干细胞移植术后并发出血性膀胱炎的止血作用研究

Research on hemostasis of hemocoagulase in patients with hemorrhagic cystitis post-ailogeneic hematopoietic stem cell transplantation

目的探讨血凝酶对异基因造血干细胞移植（allo—HSCT）术后并发出血性膀胱炎（HC）的止血作用。方法选择2010年7月至2015年12月在江苏苏州大学附属第一医院血液科接受allo—HSCT治疗后并发HC的173例患者为研究对象。将其中93例接受血凝酶治疗患者，纳入研究组；80例未接受血凝酶治疗患者，纳人对照组。研究组中Ⅰ、Ⅱ、Ⅲ及Ⅳ级HC患者分别为28、25、20及20例，而对照组中Ⅰ、Ⅱ、Ⅲ及Ⅳ级HC患者各为20例。对照组HC患者采用常规水化、碱化尿液，同时选用广谱抗病毒药物进行抗病毒治疗，但20例Ⅳ级HC患者经上述常规治疗后，出血症状均无明显改善，进一步采取数字减影血管造影（DSA）下双侧髂内动脉介入栓塞术治疗措施后，再采取常规治疗措施，最终出血停止。研究组HC患者在对照组常规治疗基础上，静脉输注血凝酶，第一阶段治疗剂量为1U／次，1次／d，如初次治疗无变态反应发生，间隔1d后，则第二阶段治疗剂量可增加至1U／次，1～2次／d，第二阶段连续用药3～7d为1个治疗周期。研究组20例Ⅳ级HC患者经常规治疗联合血凝酶治疗后，出血症状均无明显改善，故进一步采取DSA下双侧髂内动脉介入栓塞术治疗措施后，再次静脉输注血凝酶，最终出血停止。本研究按照研究组第二阶段血凝酶治疗剂量，进一步将其分为1U／d亚组（n=29）与2U／d亚组（n=64），再按照第二阶段血凝酶治疗的总剂量分为血凝酶总剂量〉6U亚组（n=62）与血凝酶总剂量≤6U亚组（n=31）。观察研究组与对照组HC持续时间，研究组血凝酶治疗前、后血小板计数与凝血相关指标，包括凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）及纤维蛋白原（Fib）水平，同时观察两组不良反应发生情况和HC复发情况。统计学比较两组HC持续时间，以及研究组的4个亚组血凝酶治疗前、后血小板计数与凝血相关指标。研究组与对照组患者的年龄、性别构成比、HC分级、疾病类型及移植方式等基线资料比较，差异均无统计学意义（P〉0．05）。本研究遵循的程序符合苏州大学附属第一医院人体试验委员会所制定的伦理学标准，得到该委员会批准。结果①研究组HC持续时间为（14．5±5．2）d，显著短于对照组的（22．5±7．7）d，并且差异有统计学意义（t=8．101，P=0．000）。研究组Ⅰ、Ⅱ及Ⅲ级HC持续时间分别为（9．7±4．5）d、（14．2±5．8）d及（23．4±8．6）d，均显著短于对照组的（17．3±8．6）d、（26．8±10．9）d及（36．5±17．8）d，并且差异均有统计学意义（t=3．949、4．979、2．967，P=0．000、0．000、0．004）。研究组与对照组Ⅳ级HC进行DSA下双侧髂内动脉介入栓塞术前，HC持续时间分别为（26．4±7．8）d与（28．0±10．9）d，二者比较，差异无统计学意义（P=0．597）；而经DSA下双侧髂内动脉介入栓塞术治疗后，再给予研究组患者血凝酶治疗，对照组再采取常规治疗措施，直至出血停止时，两组HC时间分别为（6．7±1．6）d与（9．6±2．1）d，二者比较，差异有统计学意义（t=4．912，P=0．000）。②研究组中，1U／d亚组经血凝酶治疗后，Fib水平为（2．3±0．6）g／L，低于血凝酶治疗前的（2．7±0．4）g／L，并且差异有统计学意义（t=2．987、P=0．004），而血凝酶治疗前、后PT、APTT及血小板计数比较，差异均无统计学意义（P〉0．05）。2U／d亚组、血凝酶总剂量〉6U亚组及≤6U亚组经血凝酶治疗后，Fib水平及血小板计数均较血凝酶治疗前显著下降，并且差异均有统计学意义（Fib水平比较：t=7．170、7．195、2．490，P=0．000、0．000、0．016；血小板计数比较：t=3．563、5．179、2．189，P=0．001、0．000、0．032），而血凝酶治疗前、后PT及APTT比较，差异均无统计学意义（P〉0．05）。③研究组中，3例患者出现肾功能损害，8例患者出现移值物抗宿主疾病（GVHD）；对照组中，2例出现肾功能损害，4例出现GVHD，3例出现药源性肝功能损伤。经相应治疗后，研究组和对照组上述不良反应均得以改善。④研究组中，5例患者停用血凝酶后，HC复发，再次应用血凝酶治疗2～3个周期后得到控制；最终因肺部感染与肺泡出血死亡1例，因白血病复发死亡1例。对照组中，3例HC复发，经DSA下双侧髂内动脉介入栓塞术治疗后得以控制；最终因重度肺部感染、GVHD及颅内出血，各死亡1例。结论血凝酶是一种安全、有效的止血药物，用于治疗allo—HSCT术后并发HC，可有效缩短HC持续时间。但因本研究纳入样本量较小，血凝酶治疗HC的有效性、安全性，以及是否值得临床推广，仍需要更多大样本、随机对照研究证实。

Objective To investigate the hemostatic effect of hemocoagulase in patients with hemorrhagic cystitis （ HC ） post-allogeneic hematopoietic stem cell transplantation （ allo-HSCT ）. Methods From July 2010 to December 2015, 173 cases of patients with HC of grade I -IV post-allo-HSCT in department of hematology, First Affiliated Hospital of Sooehow University were included into this study. 93 cases of patients who received hemocoagulase for HC treatment were included into research group. 80 cases of patients who did not receive hemocoagulase were chose as control group. HC of grade Ⅰ、Ⅱ、Ⅲ and Ⅳ in research group included 28, 25, 20 and 20 cases, respectively. HC of gradeⅠ、Ⅱ、Ⅲ and Ⅳ in control group included 20 cases, respectively. HC patients in control group received conventional treatment for HC.. full hydration and alkalinization of urine, and treated with broad spectrum antiviral agents. Twenty eases of grade IV HC patients in control group received bilateral embolization of internal iliac artery under digital subtraction angiography （DSA） as the conventional treatment for HC failed, and then received conventional treatment for HC again until the hemorrhage stopped. HC patients in research group received intravenous infusion of hemocoagulase on the basis of conventional treatment for HC in control group. The dose of hemocoagulase in phase one was 1 U/d, and if the patients in research group had no allergic reaction after treated for the first time, and one day later the dosage in phase two could be added to one unit once or twice daily continuously for 3-7 days as a cycle. Six cases of grade IV HC patients in research group received bilateral embolization of internal iliac artery under DSA as the hemoeoagulase treatment for HC failed, and then received hemocoagulase treatment for HC again until the hemorrhage stopped. According to the dosage of hemocoagulase in phase two, patients in research group were divided to 1 U/d subgroup （n= 29） and 2 U/d subgroup （n= 64）. And according to the total dose of hemocoagulase in phase two, patients in research group were divided the total dose of hemocoagulase ±6 U subgroup （n=62） and the total dose of hemocoagulase 46 U subgroup （n=31） again. The duration of HC, adverse effects and relapse rate were observed in each group. Platelet count and related coagulation indicators including prothrombin time （PT）, activated partial thromboplastin time （APTT） and fibrinogen （Fib） level were monitored before and after the application of hemocoagulase in research group and control group. Duration of HC in two groups, platelet count and related coagulation indicators before-hemoeoagulase and post-hemocoagulase in four subgroups of research group were analyzed by statistical methods. There were no significant differences of the age, gender ratio, grade of HC, type of diseases and transplantation methods between two groups （P〈 0.05）. The study protocol was approved by the Ethical Review Board of Investigation in the First Affiliated Hospital of Soochow University. Results ①The duration of HC in research group was （14.5±5.2） d, statistically shorter than （22.5± 7.7） d in control group, and the difference was statistically significant （t= 8. 101, P=0. 000）. The duration of grade I , Ⅱ and In HC in research group were （9. 7±4. 5） d, （14.2±5.8） d and （23.4±8. 6） d, respectively, and all were shorter than （17.3±8. 6） d, （26. 8±10.9） d, and （36. 5 ± 17. 8） d, respectively in control group, and all the differences were statistically significant （t=3. 949, 4. 979, 2. 967; P=0. 000,0. 000,0. 004）. Before receiving bilateral embolization of internal iliac artery under DSA, the duration of grade IV HC in research group and control group were （26.4±7.8） d and （28.0± 10.9） d, respectively, and there was no statistical difference between them （P=0. 597）. Grade IV HC in research group and control group were invalid after hemacoagulase treatment or conventional treatment in the observation period and received bilateral interventional embolization of internal iliac artery under DSA. After the operation, the duration of grade IV HC in research group and control group were （6.7±1. 6） d and （9.6± 2. 1） d, respectively, and the difference was statistically significant （t=4. 912, P=0. 000）. ②In 1 U/d subgroup of research group, Fib level of post-hemocoagulase was （2.3±0. 6） g/L, which was lower than that of before-hemocoagulase [（2. 7±0. 4） g/L^-1, and the difference was statistically significant （t= 2. 987, P = 0. 004）. But the PT, APTT and platelet count compared before-hemocoagulase and post-hemocoagulase, there were no statistical differences （P〈 0.05）. In the 2 U/d subgroup, total dose of hemocoagulase ±6 U subgroup and 46 U subgroup, Fib level and platelet count decreased significantly after treated with hemocoagulase, and all the differences were statistically significant （Fib level： t=7. 710, 7. 195, 2. 490; P=0. 000, 0. 000, 0. 016; platelet count： t= 3. 563, 5. 179, 2. 189; P=0. 001, 0. 000, 0. 032）. But the PT and APTT compared before-hemocoagulase and post-hemocoagulase in those three subgroups, there were no statistical differences （P〈 0.05）. ③In research group, 3 cases of patients occured kidney functional lesion and 8 cases of patients occurred graftversus-host disease （GVHD） ; while in control group, 2 cases of patients occurred kidney functional lesion, 4 cases of patients occurred GVHD and 3 cases of patients occurred drug-induced liver injury. All the adverse reactions above in two groups were improved after corresponding treatments. ④In research group, 5 cases of patients relapsed after stopping using hemocoagulase and controlled after receiving 2-3 cycles of hemocoagulase again; 1 case of patient died of pulmonary infection and pulmonary alveolar hemorrhage, 1 case of patient died of leukemia relapse. In control group, 3 cases of patients relapsed and controlled after receiving bilateral interventional embolization of internal iliac artery under DSA; 1 case of patient died of severe pulmonary infection, 1 case of patient died of GVHD, and 1 case of patient died of intracranial hemorrhage. Conclusions Hemocoagulase is one of the effective and safe hemostatics, and it can be used to treat patients with HC post-allo-HSCT. It can effectively shorten the duration of HC. As the sample size in this study is small, the effect and safety of hemocoagulase in treatment of HC post-allo-HSCT, and whether it is worthy of clinical promotion, it still needs more large samples and randomized controlled trials to confirm.