高出血风险的血液透析患者抗凝方案优化

Optimization of anticoagulation regimen for hemodialysis patients with high risk of bleeding

目的观察有出血倾向的血液透析患者采用不同抗凝方案的有效性和安全性。方法选择2018年12~2020年12月于惠州市第三人民医院维持性血液透析患者74例,按抗凝方法分为两组,简化局部枸橼酸抗凝组(S-RCA)37例、两段法枸橼酸抗凝组(TS-RCA)37例。另将2016年6月~2017年11月期间34例无抗凝剂方案患者作为无肝素组。比较各组滤器和静脉壶抗凝有效率、整体尿素清除率(spKt/V)。比较枸橼酸抗凝透析前后iCa2^(+)、iNa^(+)、pH值、HCO^(3-)水平变化、活化部分凝血活酶时间(APTT)等凝血指标变化。观察患者透析后出血情况变化,不良反应发生情况。结果S-RCA和TS-RCA组滤器和静脉壶抗凝有效率均高于无肝素组,组间差异有统计学意义(P<0.05)。TS-RCA组枸橼酸溶液输注量低于S-RCA组,组间差异均有统计学意义(P<0.05)。透析前后S-RCA组和TS-RCA组的iCa2^(+)、iNa^(+)、pH值、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)水平变化差异无统计学意义(P>0.05),两组透析后HCO^(3-)升高,与透析前比较,差异有统计学意义(P<0.05)。透析后S-RCA组和TS-RCA组APTT和血浆凝血酶原时间(PT)延长,但与透析前比较,差异无统计学意义(P>0.05)。S-RCA组和TS-RCA组的Kt/V为(1.26±0.18)、(1.31±0.15),均高于无肝素组的(1.02±0.22),组间差异有统计学意义(P<0.05)。3组透析后均未出现出血加重或新发出血,不良反应发生率差异无统计学意义(P>0.05)。结论对于高出血风险血液透析患者,S-RCA和TS-RCA的抗凝有效率和透析充分性均优于无抗凝剂方案。与简化枸橼酸抗凝相比,较低剂量的两段式枸橼酸抗凝可以减少静脉壶凝血且不会增加患者低钙血症的发生率。

Objective To observe the effectiveness and safety of different anticoagulant schemes in hemodialysis patients with bleeding tendency.Methods 74 patients with maintenance hemodialysis were divided into two groups from December 2018 to December 2020 in the third people's Hospital of Huizhou City.37 cases of S-RCA and 37 TS-RCA.34 patients without anticoagulant protocol were treated as heparin free group from June 2016 to November 2017.The anticoagulant efficiency and the overall urea clearance rate(spkt/v)of each group were compared.The changes of iCa2^(+),iNa^(+),PH and HCO^(3-)level and APTT before and after anticoagulation dialysis were compared.The bleeding and adverse reactions were observed after dialysis.Results The anticoagulant effective rates of filter and venous jug in S-RCA and TS-RCA groups were higher than those in heparin free group(P<0.05).The citrate solution infusion volume of TS RCA group was lower than that of S-RCA group(P<0.05).There were no significant differences in the levels of iCa2^(+),iNa^(+)pH,ALT and AST between S-RCA group and TS-RCA group before and after dialysis(P>0.05),but HCO^(3-)increased in the two groups after dialysis was statistically significant compared with that before dialysis(P<0.05).APTT and PT were prolonged in S-RCA group and TS-RCA group after dialysis,but the difference was not statistically significant(P>0.05).The kt/V of S-RCA group and TS-RCA group were 1.26±0.18 and 1.31±0.15,which were higher than that of non heparin group(1.02±0.22,P<0.05).There was no significant difference in the incidence of adverse reactions among the three groups(P>0.05).Conclusion For hemodialysis patients with high risk of bleeding,the anticoagulation efficiency and dialysis adequacy of S-RCA and TS-RCA are better than those of non anticoagulant regimen.Compared with simplified citrate anticoagulation,lower dose of two-stage citrate anticoagulation can reduce venous clotting without increasing the incidence of hypocalcemia.