尿激酶联合阿加曲班对维持性血液透析患者长期血管通路急性血栓形成后溶栓治疗及预防的效果

Study on thrombolytic therapy and prevention of long term vascular access in patients with MHD after acute thrombosis

目的 观察尿激酶联合阿加曲班单次溶栓治疗维持性血液透析(MHD)患者长期血管通路急性血栓形成的疗效、安全性及预防作用。方法 选择2014年1月—2017年6月西安市第九医院肾脏内科MHD血管通路栓塞的患者90例作为研究对象,随机数字表法分为观察组和对照组各45例。观察组给予尿激酶+阿加曲班溶栓治疗,对照组给予尿激酶+低分子肝素溶栓治疗。观察2组溶栓的疗效及APTT的变化;溶栓成功后2组患者均预防用药12个月,比较2组预防用药前后透析中血流量、跨膜压及静脉压变化,观察不良事件发生率及长期通畅率。结果 观察组溶栓的成功率高于对照组(80.00%vs.44.44%,χ~2=12.101,P=0.001),溶栓时间短于对照组(t=3.098,P=0.003);血流量高于对照组(t=3.375,P=0.001),跨膜压低于对照组(t=2.926,P=0.028),静脉压低于对照组(t=2.634,P=0.015);治疗后APTT时间短于对照组,但差异无统计学意义(t=1.718,P=0.089);观察组再次堵塞的发生率低于对照组(36.11%vs.55.00%,χ~2=1.873,P=0.171);观察组感染发生率低于对照组(19.44%vs.45.00%,χ~2=4.11、4=0.043);观察组溶通后平均中位通畅时间为214 d,随访1个月、3个月、6个月及12个月的通畅率分别为93.8%、85.9%、66.3%、24.9%,对照组平均中位通畅时间为152 d,随访1个月、3个月、6个月、12个月分别为88.9%、76.2%、31.9%、13.6%,仅随访6个月时观察组通畅率高于对照组(χ~2=11.383,P=0.001)。结论 尿激酶+阿加曲班比尿激酶+低分子肝素单次溶栓治疗长期血管通路急性血栓形成的效果好、安全性高,再阻塞率低及长期通畅率高。

Objective To investigate the efficacy, safety and efficacy of urokinase ＋ argatroban single thrombolysis in the treatment of acute thrombosis in patients with MHD long term vascular access. Methods Ninety cases of long term vascular access embolism in MHD Department of Nephrology, Ninth Hospital of Xi＇an from January 2014 to June 2017 were randomly divided into observation group （45 cases） and control group （45 cases）. The observation group was given urokinase ＋ Argatroban thrombolytic therapy, the control group given urokinase ＋ low molecular weight heparin for thrombolytic therapy. Both groups were treated for 12 months. The incidences of adverse events, changes in APTT, changes in blood flow, transmembrane pressure and venous pressure during and after treatment were compared between the two groups before and after treatment, and the thrombolytic effect after treatment. Results The success rate of thrombolysis in the observation group （ 80.00% ） was higher than that of the control group （44.44%） （χ^ 2=12.101, P =0.001）, and the thrombolysis time （ 6.98± 4.37） h was shorter than the control group （9.88±4.51） h （ t =3.098, P =0.003）; blood flow （248.79± 19.78 ） ml was higher than control （235.53±17.42） ml （ t =3.375, P =0.001）, transmembrane pressure （130.14± 23.16 ） mmHg was lower than control group. The venous pressure （108.56±28.62） mmHg was lower than the control group （ 118.72± 60.35） mmHg （ t =2.634, P =0.015）; APTT time after treatment （41.97±7.89）s was shorter than the control group （45.73±12.38）s, but the difference was not statistically significant （ t =1.718, P =0.089）. The incidence of re-occlusion in the observation group （36.11%） was lower than that of the control group （55.00%）. （χ ^2=1.873, P = 0.171 ）; The infection rate in the observation group was 19.44% lower than that in the control group （45.00%） （χ^ 2= 4.114 , P =0.043）; the mean median patency time in the observation group was 214 days, the patency rates in 1, 3, 6, 12 months followed up were 93.8%, 85.9%, 66.3%, and 24.9%, respectively. The mean median patency time in the control group was 152 days. The patency rate of the observation group was higher in the observation group than in the control group （χ ^2=11.383, P =0.001）. Conclusion Urokinase ＋ argatroban is superior to urokinase thrombolysis in treating long term vascular access to acute thrombosis with high safety and low rates of re-occlusion.