高出血风险患者两段法枸橼酸抗凝血液透析的临床观察

    Clinical observation of two-stage regional citrate anticoagulation in hemodialysis with high risk of bleeding

      摘要
    • 摘要: 目的 观察两段法局部枸橼酸抗凝（RCA）对高危出血风险患者进行含钙透析液高通量血液透析的安全性和有效性。方法 将具有高危出血风险的、符合RCA的89例血液透析患者分为2组。两段法RCA组（简称TS-RCA组），在透析器前持续泵入4%枸橼酸钠溶液的基础上，再在静脉壶输入前段量10%的4%枸橼酸钠溶液；简化RCA组（简称S-RCA组），仅在透析器前持续泵入4%枸橼酸钠溶液。2组均使用标准含钙透析液，且不在静脉回路补充钙剂。观察并记录患者透析治疗参数、观察透析后透析器管路凝血情况，比较2组抗凝治疗中相关参数以及抗凝有效率。结果 本研究共纳入89例患者，300例次高通量血液透析。其中180例次患者进行两段法RCA治疗，有效血流量150 ml/min，透析液流量300 ml/min，持续泵入4%枸橼酸钠的速度分别为透析器前（225.6±14.2）ml/h，透析器后静脉壶（18.5±3.3）ml/h；S-RCA组有效血流量200 ml/min，透析液流量300 ml/min，持续泵入4%枸橼酸钠的速度为透析器前（275.6±25.4）ml/h。2组组间比较，抗凝有效率在透析器部位没有统计学意义的差别（97.3%比97.7%，X2=0.024 4，P=0.876）；静脉壶部位TS-RCA组明显高于S-RCA组（96.8%比69.6%，X2=33.77，P=0.000）。结论 对于高危出血风险的血液透析患者，两段法RCA是安全的，且较简化RCA抗凝有效率明显提高，值得进一步推广。

       

      Abstract: Objective To observe the safety and efficacy of two-stage regional citrate anticoagulation (RCA) in high-flux hemodialysis with calcium-containing dialysate in patients with high risk of bleeding.Methods The maintenance hemodialysis patients with high risk of bleeding, which met criteria for citrate anticoagulation were divided into two groups. 4% citrate anticoagulation solution was infused both prior to dialyser and at venous bubble in the group of TS-RCA, and 4% citrate anticoagulation solution was only infused prior to dialyser in the group of simplified RCA (S-RCA). Standard calcium-containing dialysate was used in the groups of TS-RCA and S-RCA, and not administered with calcium supplement in venous circuit. Clinical dialysis parameters and coagulation situations of dialyser and venous bubble were observed regularly during the treatment. The above parameters were compared between the two groups.Results A total of 300 high-flux hemodialysis sessions in 89 patients were included. 180 high-flux hemodialysis sessions were treated by two-stage RCA, the effective blood volume was 150 mL/min, dialysate volume was 300 mL/min, and mean volume of 4% trisodium citrate was (225.6±14.2) mL/h prior to dialyzer and (18.5±3.3) mL/h at venous bubbler. 120 high-flux hemodialysis sessions were treated by simplified RCA, the effective blood volume was 200 mL/min, dialysate volume was 300 mL/min, and mean volume of 4% trisodium citrate was (275.6±25.4) mL/h prior to dialyzer. There was no significant difference in the effective rate of anticoagulation prior to the dialyzer between S-RCA and TS-RCA groups (97.3% vs. 97.7%, χ2=0.0244, P=0.876). The effective rate of anticoagulation at the venous bubble in the TS-RCA group was significantly higher than in the S-RCA group (96.8% vs. 69.6%, χ2=33.77, P=0.000).Conclusions Two-stage RCA is a safe and effective anticoagulation option for hemodialysis patients with high risk of bleeding. Two-stage RCA is superior to simplified RCA in the effective rate of anticoagulation, and is worth referring for dialysis clinical practice.

       

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