分段枸橼酸抗凝在高出血风险患者透析中的临床疗效分析与个体化方案研究

潘鑫; 谢攀; 卓燕; 李欢娜; 彭侃夫

doi:10.16016/j.1000-5404.202101211

您当前的位置：

首页 >

文章列表页 >

分段枸橼酸抗凝在高出血风险患者透析中的临床疗效分析与个体化方案研究

临床医学 | 更新时间：2026-01-09

- 分段枸橼酸抗凝在高出血风险患者透析中的临床疗效分析与个体化方案研究
- Clinical efficacy and individualized scheme of segmented citrate anticoagulation in dialysis of patients with high risk of bleeding
- 第三军医大学学报 2021年43卷第14期页码：1372-1378
- 作者机构：
  
  400038 重庆，陆军军医大学(第三军医大学)第一附属医院肾科
- 作者简介：
  
  [ 彭侃夫，E-mail: 392906786@qq.com PENG Kanfu, E-mail: 392906786@qq.com
- 基金信息：
  
  国家自然科学基金面上项目(81873606);国家重点研发计划(2016YFC1103003)
- DOI：10.16016/j.1000-5404.202101211
  中图分类号： R459.5;R969.4;R973.2
- 收稿：2021-01-25，
  
  修回：2021-03-05，
  
  纸质出版：2021-07-30
- 稿件说明：
移动端阅览
潘鑫, 谢攀, 卓燕, 等. 分段枸橼酸抗凝在高出血风险患者透析中的临床疗效分析与个体化方案研究[J]. 第三军医大学学报, 2021,43(14):1372-1378.

Xin PAN, Pan XIE, Yan ZHUO, et al. Clinical efficacy and individualized scheme of segmented citrate anticoagulation in dialysis of patients with high risk of bleeding[J]. Journal of Third Military Medical University, 2021, 43(14): 1372-1378.
潘鑫, 谢攀, 卓燕, 等. 分段枸橼酸抗凝在高出血风险患者透析中的临床疗效分析与个体化方案研究[J]. 第三军医大学学报, 2021,43(14):1372-1378. DOI： 10.16016/j.1000-5404.202101211.

Xin PAN, Pan XIE, Yan ZHUO, et al. Clinical efficacy and individualized scheme of segmented citrate anticoagulation in dialysis of patients with high risk of bleeding[J]. Journal of Third Military Medical University, 2021, 43(14): 1372-1378. DOI： 10.16016/j.1000-5404.202101211.

摘要

目的

对比分段枸橼酸钠抗凝(segmented citrate anticoagulation

SCA)与无肝素抗凝(non-heparin anticoagulation

NA)的安全性和有效性，探讨SCA的个体化方案。

方法

筛选2019年10月至2020年12月符合入组条件的60名高出血风险的透析患者，使用信封法随机分为SCA组和NA组

在透析过程中监测血气、电解质、ACT值，透析结束后记录滤器凝血级别、患者出血情况，比较透析前后的凝血指标，计算kt/v值和超滤量。进一步比较SCA亚组间钙离子、ACT值随时间变化的波动情况。对血浆枸橼酸钠和钙离子清除率进行回归分析。

结果

SCA组抗凝有效的比例(96.7%

63.3%)、kt/v值[(1.21±0.24)

(0.89±0.32)

]

、总超滤量[(2 033.16±708.34)

(1 584.43±868.88)mL

]

明显高于NA组(

0.05)。NA组体内ACT值缩短，SCA组未见明显变化，SCA组中红细胞压积较高[(0.32±0.07)

(0.23±0.04)

0.05

]

的部分患者体外ACT值延长到理想倍数。血浆枸橼酸钠流速与钙离子清除率存在显著线性关系(

=14.671，

0.05)。

结论

SCA在抗凝的有效性和透析的充分性上明显优于NA，不易形成微血栓，在部分患者中可实现个体化的理想抗凝方案。

Abstract

Objective

To compare the safety and effectiveness of anticoagulation strategies between segmented citrate anticoagulation (SCA) and non-heparin anticoagulation (NA)

and investigate the individualized scheme of SCA.

Methods

Sixty patients who met our inclusion criteria and underwent dialysis due to acute and chronic renal failure in our department from October 2019 to December 2020 were recruited in this study

and were randomly divided into SCA group and NA group. Blood gas

electrolyte and activated clotting time (ACT) were monitored during dialysis. The coagulation grade of the filter and hemorrhagic condition were recorded after dialysis. The coagulation indexes before and after dialysis were compared

and the kt/v value and total ultrafiltration volume were calculated. The fluctuation of calcium ion and ACT value among SCA subgroups were further compared. Plasma sodium citrate and calcium clearance were analyzed by regression analysis.

Results

The percentage of effective anticoagulation (96.7%

63.3%)

kt/v value (1.21±0.24

0.89±0.32) and total ultrafiltration volume (2 033.16±708.34

1 584.43±868.88 mL) were significantly higher in the SCA group than the NA group (

0.05). The ACT value was shortened in the NA group

but no such change was seen in the SCA group. In some SCA patients with high hematocrit (0.32±0.07

0.23±0.04

0.05)

their ACT value was prolonged to the ideal multiple. There was a significant linear relationship between plasma sodium citrate flow rate and calcium clearance rate (

=14.671

0.05).

Conclusion

SCA is superior to NA in anticoagulant efficacy

dialysis adequacy and prevention of microthrombosis. An ideal anticoagulant regimen can be realized in part of patients.

关键词

Keywords

references

MOLNAR A O, BOTA S E, GARG A X, et al , The risk of major hemorrhage with CKD[J ] . J Am Soc Nephrol, 2016, 27(9): 2825-2832. DOI:10.1681/ASN.2015050535.

TRIVEDI H, YANG J, SZABO A. Gastrointestinal bleeding in patients on long-term dialysis[J]. J Nephrol, 2015, 28(2): 235-243. DOI:10.1007/s40620-014-0132-6.

GALBUSERA M, REMUZZI G, BOCCARDO P. Boccardo, Treatment of bleeding in dialysis patients[J]. Semin Dial, 2009, 22(3): 279-286. DOI:10.1111/j.1525-139X.2008.00556.x.

LEROY C, PEREIRA B, SOUM E, et al , Comparison between regional citrate anticoagulation and heparin for intermittent hemodialysis in ICU patients: a propensity score-matched cohort study[J ] . Ann Intensive Care, 2021, 11(1): 13. DOI:10.1186/s13613-021-00803-x.

DI MARIO F, REGOLISTI G, DI MARIA A, et al . Sustained low-efficiency dialysis with regional citrate anticoagulation in critically ill patients with COVID-19 associated AKI: a pilot study[J ] . J Crit Care, 2021, 63: 22-25. DOI:10.1016/j.jcrc.2021.01.013.

KHWAJA A. KDIGO clinical practice guidelines for acute kidney injury[J]. Nephron Clin Pract, 2012, 120(4): c179-c184. DOI:10.1159/000339789.

LUO L, FAN M, CHEN Q, et al . A simplified protocol for individualized regional citrate anticoagulation for hemodialysis: a single-center, randomized clinical study[J ] . Medicine (Baltimore), 2021, 100(8): e24639. DOI:10.1097/md.0000000000024639.

LIN T, SONG L, HUANG R W, et al . Modified regional citrate anticoagulation is optimal for hemodialysis in patients at high risk of bleeding: a prospective randomized study of three anticoagulation strategies[J ] . BMC Nephro l, 2019, 20(1): 472. DOI:10.1186/s12882-019-1661-y.

席春生, 刘飞, 刘同存, 等. 高出血风险患者两段法枸橼酸抗凝血液透析的临床观察[J]. 临床肾脏病杂志, 2018(3): 141-144. DOI:10.3969/j.issn.1671-2390.2018.03.003.

XI C S, LIU F, LIU T C, et al . Clinical observation of two-stage regional citrate anticoagulation in hemodialysis with high risk of bleeding[J ] . J Clin Nephrol, 2018(3): 141-144. DOI:10.3969/j.issn.1671-2390.2018.03.003.

张东亮, 张潘, 张周沧. 分段枸橼酸抗凝进行含钙透析液高通量血液透析的临床观察[J]. 中国血液净化, 2016, 15(12): 686-690. DOI:10.3969/j.issn.1671-091.2016.12.009.

ZHANG D L, ZHANG P, ZHANG Z C. Observational study of segmented citrate anticoagulation in high flux hemodialysis with calcium-containing dialysate[J]. Chin J Blood Purif, 2016, 15(12): 686-690. DOI:10.3969/j.issn.1671-091.2016.12.009.

KINDGEN-MILLES D, BRANDENBURGER T, DIMSKI T. Regional citrate anticoagulation for continuous renal replacement therapy[J]. Curr Opin Crit Care, 2018, 24(6): 450-454. DOI:10.1097/MCC.0000000000000547.

LIN T, SONG L, HUANG R W, et al , Modified regional citrate anticoagulation is optimal for hemodialysis in patients at high risk of bleeding: a prospective randomized study of three anticoagulation strategies[J ] . BMC Nep hrol, 2019, 20(1): 472. DOI:10.1186/s12882-019-1661-y.

BRANDL M, STROBL K, HARTMANN J, et al . A target-orientated algorithm for regional citrate-calcium anticoagulation in extracorporealtherapies[J ] . Blood Purif, 2012, 33(1/3): 7-20. DOI:10.1159/000332394.

ARACHCHILLAGE D R J, LAFFAN M. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia[J]. J Thromb Haemost, 2020, 18(5): 1233-1234. DOI:10.1111/jth.14820.

KARA H, BAYIR A, DEGIRMENCI S, et al . D-dimer and D-dimer/fibrinogen ratio in predicting pulmonary embolism in patients evaluated in a hospital emergency department[J ] . Acta Clin Belg, 2014, 69(4): 240-245. DOI:10.1179/2295333714y.0000000029.

ZIMBUDZI E. Intermittent saline flushes or continuous saline infusion: what works better when heparin-free dialysis is recommended?[J]. Int J Nephrol Renovasc Dis, 2013, 6: 65-69. DOI:10.2147/ijnrd.s43252.

SAGEDAL S, HARTMANN A, OSNES K, et al . Intermittent saline flushes during haemodialysis do not alleviate coagulation and clot formation in stable patients receivi ng reduced doses of dalteparin[J ] . Nephrol Dial Transplant, 2006, 21(2): 444-449. DOI:10.1093/ndt/gfi203.

National Kidney Foundation. KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update[J]. Am J Kidney Dis, 2015, 66(5): 884-930. DOI:10.1053/j.ajkd.2015.07.015.

LOCKRIDGE R, TING G, KJELLSTRAND C M, et al . Superior patient and technique survival with very high standard Kt/V in quotidian home hemodialysis[J ] . Hemodial Int, 2012, 16(3): 351-362. DOI:10.1111/j.1542-4758.2012.00696.x.

张少岩, 李月红, 杨画, 等. 简化枸橼酸抗凝血液透析治疗方案在高出血风险患者血液透析中的应用[J]. 临床内科杂志, 2021(1): 34-36. DOI:10.3969/j.issn.1001-9057.2021.01.009.

ZHANG S Y, LI Y H, YANG H, et al . Application of simplified regional citrate anticoagulation in hemodialysis of patients with high-risk of bleeding[J ] . J Clin Intern Med, 2021(1): 34-36. DOI:10.3969/j.issn.1001-9057.2021.01.009.

潘鑫, 谢攀, 卓燕, 等. 枸橼酸钠抗凝在不同血液净化模式中的应用[J]. 中国血液净化, 2020, 19(8): 543-546. DOI:10.3969/j.issn.1671-4091.2020.08.010.

PAN X, XIE P, ZHUO Y, et al . Application of regional citrate anticoagulation in different blood purification modalities[J ] . Chin J Blood Purif, 2020, 19(8): 543-546. DOI:10.3969/ j.issn.1671-4091.2020.08.010.

LIM E K, SEOW Y T, CHEN S E, et al . Simple citrate anti coagulation protocol for low flux haemodialysis[J ] . BMC Nephrol, 2018, 19(1): 16. DOI:10.1186/s12882-018-0811-y.

SCARFOGLIÈRE V, BOBOT M, Guilhem C, et al . Regional anticoagulation with calcium-free dialysate containing citrate in chronic hemodialysis patients[J ] . Nephrol Dial Transplant, 2021, 36(4): 745-746. DOI:10.1093/ndt/gfaa365.

WEN M, KVCHLE C, STEUBL D, et al . A novel citrate-based protocol versus heparin anticoagulation for sustained low-efficiency dialysis in the ICU: safety, efficacy, and cost[J ] . BMC Nephrol, 2018, 19(1): 79. DOI:10.1186/s12882-018-0879-4.

ZHENG Y, XU Z, ZHU Q, et al . Citrate pharmacokinetics in critically ill patients with acute kidney injury[J ] . PLoS ONE, 2013, 8(6): e65992. DOI:10.1371/journal.pone.0065992.

STROBL K, HARTMANN J, WALLNER M, et al . A target-oriented algorithm for citrate-calcium anticoagulation in clinical practice[J ] . Blood Purif, 2013, 36(2): 136-145. DOI:10.1159/000355012.

浏览量

下载量

CSCD

文章被引用时，请邮件提醒。

提交

工具集

关联资源

常规超声及三维斑点追踪成像技术对血液透析患者自体动静脉内瘘成熟的预测价值

共享决策干预在终末期肾脏病患者透析治疗决策中的应用

超声引导下深静脉穿刺置管术建立血管通路在血液透析中的应用

缬沙坦对糖尿病肾病血液透析患者血压及血压变异性的影响

维持性血液透析患者症状负担与生活质量相关性研究