局部枸橼酸抗凝在高危出血风险血液透析患者中的应用

Application of regional citrate anticoagulation to patients with hemodialysis at high risk of bleeding

目的探索局部枸橼酸抗凝(RCA)在高危出血风险的血液透析(HD)患者中应用的效果以及安全性。方法纳入武汉大学人民医院肾内科以及宜城市人民医院肾病内科中具有高危出血风险的HD患者20例,采用4%枸橼酸钠局部抗凝进行HD治疗,搜集并比较患者透析前后血钾、血清游离钙、总钙、血钠、血氯、p H值、血肌酐、尿素氮、透析2 h滤器末端钙离子浓度,激活凝血时间等的变化,并观察患者透析过程中出血、体外循环的凝血情况、不良反应(口唇发麻,肢体抽搐,肌痉挛)等情况。结果20例患者总共完成70例次H D,透析时间均为4 h。透析后血钾、血肌酐、尿素氮较透析前下降,有统计学意义(P<0.05),透析2 h时滤器末端钙离子浓度为(0.58±0.20)m m ol/L;透析后p H值、激活凝血时间、血氯、血清游离钙、总钙、血钠与透析前比较差异无统计学意义(P>0.05)。其余患者均成功转为低分子肝素透析(95%)。无透析中出血或原有出血加重的情况,其中有3例次I级凝血,发生率为4.3%。4例患者出现低钙表现,发生率为20%;1例脑出血患者因脑疝加重放弃治疗(5%)。结论局部枸橼酸抗凝对于高危出血风险的HD患者疗效显著,具有较好的安全性,使用过程中注意监测血钙。

Objective To explore the effect and safety of regional citrate anticoagulation in patients with hemodialysis at high risk of bleeding. Methods Twenty patients with hemodialysis at high risk of bleeding were enrolled,and 4% sodium citrate was used for hemodialysis.Blood K ＋,serum total calcium,serum sodium,blood chloride,blood pH value,serum creatinine,blood urea nitrogen,calcium ion concentration at filter end of dialysis 2 h,activated clotting time before and after hemodialysis were analyzed. Bleeding during hemodialysis,coagulation in extracorporeal circulation,and adverse reactions（ lips numbness,limb convulsions,muscle spasms） were observed. Results Twenty patients underwent 70 case-times of hemodialysis and hemodialysis time was 4 h. Blood K ＋,serum creatinine,and urea nitrogen after hemodialysis were significantly reduced as compared with those before hemodialysis（ P〈0. 05）. The concentrations of calcium ion at the end of the filter was（ 0. 58 ± 0. 20） mmol/L after dialysis at 2 h,and the blood glucose was significantly lower than that before dialysis（ P〈0. 05）. There was no significant difference in pH value,activated clotting time,blood Cl-,serum total calcium concentration and blood Na ＋ before and after hemodialysis（ P〉0. 05）. Hypocalcemia occurred in 4 cases（ 20%）,and one case of cerebral hemorrhage withdrew the treatment due to aggravatedhernia hernia. No bleeding or bleeding aggravation occurred in hemodialysis. There were 3 cases of grade I coagulation（ 4. 3%）. Conclusions Regional citrate anticoagulation is effective in hemodialysis patients with high risk of hemorrhage,and has good safety. During the course of treatment,blood calcium is monitored.