阿替普酶静脉溶栓治疗老年急性脑梗死并维持性透析患者的疗效及安全性

Efficacy and safety of thrombolytic therapy with intravenous alteplase in elderly patients with acute cerebral infarction on maintenance dialysis

目的探讨阿替普酶(rt-PA)静脉溶栓治疗老年急性脑梗死并维持性血液透析患者的疗效及安全性。方法回顾性研究,选取2018年5月至2021年3月在南开大学附属第四中心医院卒中中心救治的急性脑梗死并维持性血液透析的老年患者的临床资料,其中165例65~85岁患者入选。依据是否进行阿替普酶(rt-PA)静脉溶栓及溶栓方案的不同,将患者分为保守治疗组(58例,仅接受标准化二级预防治疗)、rt-PA小剂量组(57例,接受rt-PA静脉溶栓,剂量为0.6 mg/kg)和rt-PA标准剂量组(50例,接受rt-PA静脉溶栓,剂量为0.9 mg/kg)。评价rt-PA静脉溶栓的有效性和安全性。结果治疗24 h的有效率和7 d良好率,rt-PA小剂量组分别为64.9%(37/57)和70.2%(40/57),rt-PA标准剂量组分别为68.0%(34/50)和74.0%(37/50),两组对比差异无统计学意义(χ^(2)=0.417,P=0.518;χ^(2)=0.636,P=0.425),但均优于保守治疗组的29.3%(17/58)和41.4%(24/58)(χ^(2)=10.583、16.714,P<0.001)。90 d的预后良好率,三组分别为73.7%(42/57)、78.0%(39/50)和69.0%(40/58),差异无统计学意义(χ^(2)=1.126,P=0.569),但rt-PA小剂量组的病死率为7.0%(4/57),低于rt-PA标准剂量组的18.0%(9/50)(χ^(2)=5.420,P=0.020)和保守治疗组的20.0%(8/58)(χ^(2)=5.048,P=0.025)。颅内出血发生率,rt-PA小剂量组为8.8%(5/57),低于rt-PA标准剂量组的24.0%(12/50)(P=0.032)。rt-PA小剂量组的颅外并发症发生率为15.8%(9/57),低于rt-PA标准剂量组36.0%(18/50)(P=0.017)。结论老年急性脑梗死并维持性血液透析的患者,可慎重选择小剂量rt-PA静脉溶栓治疗。

Objective To investigate the efficacy and safety of thrombolytic therapy with intravenous alteplase(rt-PA)for elderly acute ischemic stroke patients on maintenance hemodialysis.MethodsIn this retrospective study,data of 165 elderly patients with acute cerebral infarction on maintenance dialysis,aged 65-85,treated at the Stroke Center of the Fourth Central Hospital Affiliated to Nankai University between May 2018 and March 2021,were collected.Based on whether intravenous thrombolysis with alteplase(rt-PA)was used and differences in thrombolytic schemes,patients were divided into a conservative treatment group(n=58,receiving only standardized secondary stroke prevention),a low-dose rt-PA group(n=57,receiving rt-PA intravenous thrombolysis,0.6 mg/kg)and a standard-dose rt-PA group(n=50,receiving rt-PA intravenous thrombolysis,0.9 mg/kg).The safety and efficacy of rt-PA treatment were assessed.ResultsThe rate of effectiveness at 24 h and the rate of good prognosis at 7 d were 64.9%(37/57)and 70.2%(40/57)for the low-dose rt-PA group and 68.0%(34/50)and 74.0%(37/50)for the standard dose group,respectively.There was no significant difference between the two groups(χ^(2)=0.417,P=0.518;χ^(2)=0.636,P=0.425),but these rates were better than 29.3%(17/58)and 41.4%(24/58)for the conservative treatment group(χ^(2)=10.583、16.714,P<0.001).The good prognosis rate at 90 days were 73.7%(42/57),78.0%(39/50)and 69.0%(40/58)for the three groups,respectively,with no significant difference(χ^(2)=1.126,P=0.569),but the fatality rate for the low-dose rt-PA group was 7.0%(4/57),lower than 18.0%(9/50)(χ^(2)=5.420,P=0.020)for the standard dose rt-PA group and 20.0%(8/58)for the conservative treatment group(χ^(2)=5.048,P=0.025).The incidence of intracranial hemorrhage was 8.8%(5/57)for the low-dose rt-PA group,lower than 24.0%(12/50)for the standard-dose rt-PA group(P=0.032).The incidence of extracranial complications was 15.8%(9/57)for the low-dose rt-PA group,lower than 36.0%(18/50)for the standard-dose group(P=0.017).ConclusionsFor elderly patients with acute cerebral infarction on maintenance hemodialysis,intravenous thrombolytic therapy with low dose rt-PA should be considered with caution.