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血液透析中的抗凝治疗

Author
Eugene C Kovalik, MD
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD
Translators
于峰, 主任医师，教授

引言

血液透析及连续性肾脏替代疗法需要进行体外血液循环。为了预防血流通路中血栓形成，需采用某种抗凝方法(通常使用肝素)。使出血风险最小化的策略包括低剂量或“最小剂量肝素”，以及高流速“无肝素”抗凝法。也已使用枸橼酸盐、前列环素及肝素-鱼精蛋白进行局部抗凝。这些抗凝方法诱发的出血倾向，对于晚期肾衰竭通常存在的血小板功能障碍具有加性作用。(参见“尿毒症血小板功能障碍”)

可通过测定活化凝血时间(activated clotting times, ACT)来监测血液透析期间的抗凝状况。然而，尽管ACT和全血凝血时间相比具有可自动分析并快速得出结果的优势，但因质量保证和注册方面的问题，并不常用。

一般而言，大多数门诊透析中心不会常规检测抗凝参数，除非出现透析器凝血或透析后出血时间延长。每个透析中心通常都会有一套自身遵循的流程方案。

标准抗凝方案

常规血液透析中的抗凝治疗包括：在透析治疗开始时，单次快速给予标准剂量的肝素，且在透析治疗中间再给予一剂肝素，以维持适当的抗凝效果。或者，可通过肝素建模，初始推注肝素，随后进行恒定的固定剂量输注，将ACT维持在200-250s(正常为90-140s)。

ACT(活化全血凝血时间)的检测方法是：向新抽取的全血样本中加入一种活化剂(例如，硅藻土、白陶土)，随后测定形成血凝块的时间(以秒为单位)。(参见“凝血检测的临床应用”)这一治疗方案确保了透析治疗全过程中的全身性抗凝状态。该方法较为可靠，且在确定患者的肝素剂量(基于ACT目标值)后，只需要最低程度的人员干预。

                  

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Literature review current through: 2017-06 . | This topic last updated: 2015-07-21.
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References
Top
  1. Ouseph R, Brier ME, Ward RA. Improved dialyzer reuse after use of a population pharmacodynamic model to determine heparin doses. Am J Kidney Dis 2000; 35:89.
  2. Lohr JW, Schwab SJ. Minimizing hemorrhagic complications in dialysis patients. J Am Soc Nephrol 1991; 2:961.
  3. Sanders PW, Taylor H, Curtis JJ. Hemodialysis without anticoagulation. Am J Kidney Dis 1985; 5:32.
  4. Stamatiadis DN, Helioti H, Mansour M, et al. Hemodialysis for patients bleeding or at risk for bleeding, can be simple, safe and efficient. Clin Nephrol 2004; 62:29.
  5. Schwab SJ, Onorato JJ, Sharar LR, Dennis PA. Hemodialysis without anticoagulation. One-year prospective trial in hospitalized patients at risk for bleeding. Am J Med 1987; 83:405.
  6. Sepulveda S, Davis L, Schwab SJ. Blood transfusion during heparin-free hemodialysis. Kidney Int 1997; 51:2018.
  7. Swartz RD, Port FK. Preventing hemorrhage in high-risk hemodialysis: regional versus low-dose heparin. Kidney Int 1979; 16:513.
  8. GORDON LA, PERKINS HA, RICHARDS V, et al. Studies in regional heparinization. II. Artificial-kidney hemodialysis without systemic heparinization; preliminary report of a method using simultaneous infusion of heparin and protamine. N Engl J Med 1956; 255:1063.
  9. Maher JF, Lapierre L, Schreiner GE, et al. Regional heparinization for hemodialysis. N Engl J Med 1963; 268:451.
  10. Lindholm DD, Murray JS. A simplified method of regional heparinization during hemodialysis according to a predetermined dosage formula. Trans Am Soc Artif Intern Organs 1964; 10:92.
  11. Spencer P, Cozzi E, Easterling RE, Penner JA. Regional heparinization with the hollow fiber artificial kidney. Proc Am Assoc Nephrol Nurses Technicians 1977; 4:69.
  12. Congdon JE, Kardinal CG, Wallin JD. Monitoring heparin therapy in hemodialysis. A report on the activated whole blood coagulation time tests. JAMA 1973; 226:1529.
  13. Blaufox MD, Hampers CL, Merrill JP. Rebound anticoagulation occurring after regional heparinization for hemodialysis. Trans Am Soc Artif Intern Organs 1966; 12:207.
  14. Pinnick RV, Wiegmann TB, Diederich DA. Regional citrate anticoagulation for hemodialysis in the patient at high risk for bleeding. N Engl J Med 1983; 308:258.
  15. von Brecht JH, Flanigan MJ, Freeman RM, Lim VS. Regional anticoagulation: hemodialysis with hypertonic trisodium citrate. Am J Kidney Dis 1986; 8:196.
  16. Janssen MJ, Huijgens PC, Bouman AA, et al. Citrate versus heparin anticoagulation in chronic haemodialysis patients. Nephrol Dial Transplant 1993; 8:1228.
  17. Flanigan MJ, Von Brecht J, Freeman RM, Lim VS. Reducing the hemorrhagic complications of hemodialysis: a controlled comparison of low-dose heparin and citrate anticoagulation. Am J Kidney Dis 1987; 9:147.
  18. Apsner R, Buchmayer H, Lang T, et al. Simplified citrate anticoagulation for high-flux hemodialysis. Am J Kidney Dis 2001; 38:979.
  19. Apsner R, Buchmayer H, Gruber D, Sunder-Plassmann G. Citrate for long-term hemodialysis: prospective study of 1,009 consecutive high-flux treatments in 59 patients. Am J Kidney Dis 2005; 45:557.
  20. Morgera S, Haase M, Ruckert M, et al. Regional citrate anticoagulation in continuous hemodialysis--acid-base and electrolyte balance at an increased dose of dialysis. Nephron Clin Pract 2005; 101:c211.
  21. Ahmad S, Callan R, Cole JJ, Blagg CR. Dialysate made from dry chemicals using citric acid increases dialysis dose. Am J Kidney Dis 2000; 35:493.
  22. Tu A, Ahmad S. Heparin-free hemodialysis with citrate-containing dialysate in intensive care patients. Dial Transplant 2000; 29:620.
  23. Swartz RD, Flamenbaum W, Dubrow A, et al. Epoprostenol (PGI2, prostacyclin) during high-risk hemodialysis: preventing further bleeding complications. J Clin Pharmacol 1988; 28:818.
  24. Caruana RJ, Smith MC, Clyne D, et al. Controlled study of heparin versus epoprostenol sodium (prostacyclin) as the sole anticoagulant for chronic hemodialysis. Blood Purif 1991; 9:296.
  25. Ota K, Kawaguchi H, Takahashi K, Ito K. A new prostacyclin analogue - an anticoagulant applicable to hemodialysis. Trans Am Soc Artif Intern Organs 1983; 29:419.
  26. Matsuo T, Kario K, Nakao K, et al. Anticoagulation with nafamostat mesilate, a synthetic protease inhibitor, in hemodialysis patients with a bleeding risk. Haemostasis 1993; 23:135.
  27. Lim W, Cook DJ, Crowther MA. Safety and efficacy of low molecular weight heparins for hemodialysis in patients with end-stage renal failure: a meta-analysis of randomized trials. J Am Soc Nephrol 2004; 15:3192.
  28. Vanuytsel JL, Lins RL, Zachée P, et al. Comparison of different routes of administration of nadroparin in hemodialysis. Clin Nephrol 1999; 52:322.
  29. Janssen MJ, Deegens JK, Kapinga TH, et al. Citrate compared to low molecular weight heparin anticoagulation in chronic hemodialysis patients. Kidney Int 1996; 49:806.
  30. Schrader J, Stibbe W, Kandt M, et al. Low molecular weight heparin versus standard heparin. A long-term study in hemodialysis and hemofiltration patients. ASAIO Trans 1990; 36:28.
  31. Polkinghorne KR, McMahon LP, Becker GJ. Pharmacokinetic studies of dalteparin (Fragmin), enoxaparin (Clexane), and danaparoid sodium (Orgaran) in stable chronic hemodialysis patients. Am J Kidney Dis 2002; 40:990.
  32. van Wyk V, Badenhorst PN, Luus HG, Kotzé HF. A comparison between the use of recombinant hirudin and heparin during hemodialysis. Kidney Int 1995; 48:1338.
  33. Fischer KG, van de Loo A, Böhler J. Recombinant hirudin (lepirudin) as anticoagulant in intensive care patients treated with continuous hemodialysis. Kidney Int Suppl 1999; :S46.
  34. Evenepoel P, Dejagere T, Verhamme P, et al. Heparin-coated polyacrylonitrile membrane versus regional citrate anticoagulation: a prospective randomized study of 2 anticoagulation strategies in patients at risk of bleeding. Am J Kidney Dis 2007; 49:642.
  35. European Best Practice Guidelines Expert Group on Hemodialysis, European Renal Association. Section II. Haemodialysis adequacy. Nephrol Dial Transplant 2002; 17 Suppl 7:16.
  36. Murray PT, Reddy BV, Grossman EJ, et al. A prospective comparison of three argatroban treatment regimens during hemodialysis in end-stage renal disease. Kidney Int 2004; 66:2446.
  37. Henny CP, ten Cate H, Surachno S, et al. The effectiveness of a low molecular weight heparinoid in chronic intermittent haemodialysis. Thromb Haemost 1985; 54:460.
  38. Weijmer MC, van den Dorpel MA, Van de Ven PJ, et al. Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 2005; 16:2769.
  39. Farthing C, Krishnan M, Mayne T, et al. Tego Connectors Reduce Heparin Use Without Affecting Blood Flow Rate Compared to Traditional Central Venous Catheter Locks. American Nephrology Nurses' Association 43rd National Symposium. Orlando, FL. April 29-May 2, 2012.
  40. O'Shea SI, Ortel TL, Kovalik EC. Alternative methods of anticoagulation for dialysis-dependent patients with heparin-induced thrombocytopenia. Semin Dial 2003; 16:61.