简化法局部枸橼酸与阿加曲班抗凝在高危出血风险血液透析患者中的对比观察

Comparative observation of anticoagulant effect of simplified-regional citrate and argatroban in patients with hemodialysis at high risk of bleeding

目的观察简化法局部枸橼酸抗凝(simplified-regional citrate anticoagulation,SRCA)与小剂量阿加曲班(Argatroban)抗凝在高危出血风险维持性血液透析(maintenance hemodialysis,MHD)患者中的抗凝效果。方法选取空军特色医学中心血液净化中心2017年2月至2019年5月具有活动性出血或出血倾向的32例血液透析患者,随机分为S-RCA组(A组),阿加曲班组(B组)。A组在体外循环管路起始端持续泵入4%枸橼酸至透析结束,静脉壶不追加枸橼酸,静脉回路不补钙,B组在滤器前持续泵入小剂量阿加曲班(0.69μg·kg-1·min-1)至透析结束,两组均使用含钙(1.5 mmol/L)透析液。观察透析充分性、滤器和静脉壶抗凝有效率、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)及滤器前后游离钙(iCa2+)变化,记录不良反应及出血事件。结果(1)两组患者均顺利完成4 h血液透析治疗,两组透析充分性Kt/v无明显差异(1.33±0.16 vs 1.26±0.06,P=0.129)。(2)A组与B组滤器抗凝有效率无统计学差异(P=0.600),静脉壶抗凝有效率A组优于B组(93.75%vs 56.25%,P=0.037)。(3)B组透析后APTT较A组明显延长(40.4±8.2 vs 28.8±1.6,P<0.001),B组透析2h滤器前、后及透析后APTT较同组透析前均延长(40.0±4.8 vs 39.8±7.2,40.4±8.2 vs 30.7±1.8,P均为<0.01),B组透析后1 h APTT较透析前仍延长(38.8±7.4 vs 30.7±1.8,P=0.003)。(4)A组透析后iCa2+略高于HD前(1.13±0.06 vs 1.06±0.10,P=0.012),虽略升高,但仍处于正常范围内。(5)A组出现1例口唇麻木,经调整枸橼酸流速和补钙治疗后好转,B组出现1例皮下瘀斑,后自行好转,无明显新发出血或原有出血加重。结论对于高危出血风险MHD患者,S-RCA优于小剂量阿加曲班法,较常用的两段法局部枸橼酸抗凝更具优势。

Objective To observe the anticoagulant effects of simplified-regional citrate anticoagulation(S-RCA)and small-dose argatroban in patients with maintenance hemodialysis(MHD)at highrisk of bleeding.Methods We selected 32 hemodialysis patients with active bleeding or bleeding tendency from February 2017 to May 2019 in the blood purification center of our hospital,who were randomly divided into S-RCA group(group A)and argatroban group(group B).For patients in the group A,4%citrate was continuously pumped into the starting end of the in vitro pipeline system till the end of dialysis;citrate was not supplemented in the venous bubble trap and calcium was not added in the venous circuit.Patients in the group B received a small dose(0.69μg·kg-1·min-1)of argatroban that was pumped continuously in front of the filter during the dialysis.Calcium dialysate(1.5 mmol/L)was applied to both groups.We observed dialysis sufficiency,anticoagulation efficacy of the filter and venous bubble trap,activated partial thromboplastin time(APTT),change of pre-and post-filtration free calcium(iCa2+),and recorded adverse reactions and bleeding events.Results(1)Patients in both of groups successfully completed 4 h hemodialysis.There was no significant difference in dialysis sufficiency(Kt/v)between group A and group B(1.33±0.16 vs 1.26±0.06,P=0.129).(2)There was no significant difference in the anticoagulation efficiency of the filter between group A and group B(P=0.600).The anticoagulant efficiency of venous bubble trap in group A was better than that in group B(93.75%vs 56.25%,P=0.037).(3)The post-HD APTT in group B was significantly longer than that in group A(40.4±8.2 vs 28.8±1.6,P<0.01).The pre-and post-filtration APTT during 2h HD and APTT after HD were both longer than those before HD in the group B(40.0±4.8 vs 39.8±7.2,40.4±8.2 vs 30.7±1.8,P<0.01).The APTT at 1 hour after dialysis in group B was still significantly longer than that before HD(38.8±7.4 vs 30.7±1.8,P=0.003).(4)In group A,iCa2+after HD in was slightly higher than that measured before HD(1.13±0.06 vs 1.06±0.10,P=0.012),but still in the normal range.(5)One patient in group A experienced lip numbness and improved after citrate flow rate adjustment and calcium supplements.One patient in group B had subcutaneous ecchymosis,but improved spontaneously with no newly or exacerbated bleeding.Conclusions For MHD patients at high risk of bleeding,S-RCA is superior to low dose argatroban method and has more advantages than two-stage RCA anticoagulant method.