小剂量阿加曲班联合枸橼酸体外抗凝的疗效

doi:10.3969/j.issn.1006-298X.2018.04.007

肾脏病与透析肾移植杂志 ›› 2018, Vol. 27 ›› Issue (4): 331-335.DOI: 10.3969/j.issn.1006-298X.2018.04.007

小剂量阿加曲班联合枸橼酸体外抗凝的疗效

出版日期:2018-08-28 发布日期:2018-08-31

Effect and safety of low dose argatroban plus regional citrate anticoagulation in extracorporeal circulation

Online:2018-08-28 Published:2018-08-31

摘要/Abstract

摘要：

目的：初步观察连续性肾脏替代治疗(CRRT)采用常规抗凝方法（小剂量低分子肝素联合枸橼酸）疗效不佳者切换为小剂量阿加曲班联合枸橼酸抗凝后的效果及安全性。
方法：入选南京总医院国家肾脏疾病临床医学研究中心ICU接受CRRT并采用小剂量低分子肝素联合枸橼酸抗凝效果不理想(滤器寿命<24h)，且因可能存在的出血风险无法进一步增加低分子肝素剂量的患者，入选后改为小剂量阿加曲班联合枸橼酸抗凝治疗。主要观察切换抗凝方案后滤器使用寿命，其次是治疗期间出血发生率及患者凝血功能、血细胞变化情况。
结果：入选20例患者，原抗凝方案中低分子肝素首剂352±1043 IU/kg,维持剂量33±089 IU/（kg·h），联合局部枸橼酸抗凝(RCA)。如滤器寿命不足24h即入选。RCA维持原方案不变，在更换新滤器时用阿加曲班替代低分子肝素，首剂459±1402 μg/kg，维持剂量012±005 μg/（kg·min）。生存分析显示，在抗凝方案切换前中位滤器寿命140 h（95%CI,791～2010 h）；切换后中位生存时间明显延长至480h（95%CI 251～7093，P＜0001）。阿加曲班联合枸橼酸治疗对Hb、凝血酶原时间、活化部分凝血酶原时间、国际标准化比值和纤维蛋白原水平无明显影响；血小板及白细胞计数出现下降（P<005），但幅度很小。20例患者在抗凝方案切换前后及研究结束后72h内均未发生出血相关并发症。
结论：CRRT采用低分子肝素联合枸橼酸抗凝效果不理想时，切换为小剂量阿加曲班联合枸橼酸抗凝后滤器使用寿命明显延长，达到满意抗凝效果，且对凝血功能无明显影响、出血相关不良反应无明显增加。

关键词: 阿加曲班, 低分子肝素, 局部枸橼酸抗凝, 连续性肾脏替代治疗

Abstract:

Ｏｂｊｅｃｔｉｖｅ：To investigate the anticoagulation effect and safety of low dose argatroban combined with citrate when the anticoagulation with low molecular weight heparin (LMWH) and citrate was ineffective in continuous renal replacement therapy (CRRT).
Ｍｅｔｈｏｄｏｌｏｇｙ：From September 2015 to May 2017,twenty CRRT treated AKI patients complicated with risk of bleeding were enrolled in this selfcontrolled，prospective，observational study in ICU of Jinling Hospital (Nanjing,China).The prescription of original anticoagulation therapy was LMWH 20～50 IU/kg at bolus and 5 IU/(kg·h) as maintenance,combined with 13% trisodium citrate 50～60 ml/h.Time to replaced by argatroban 30～50 μg/kg at bolus and 01～03 μg/(kg·min) as maintenance,when the given protocol of LMWH was not enough to maintain the filter life >24h and not to increase the dose of LMWH in case of increase risk of bleeding.The modality of CRRT,type of filter and dose of citrate were not changed during the study.Primary observational outcome was filters′ functional life before/after the switch of anticoagulation therapy.
Ｒｅｓｕｌｔｓ：The median doses of anticoagulants adjusted by body weight were LMWH (352±1043) IU/kg at bolus and (33±089) IU/(kg·h) as maintenance,argatroban adjusted by body weight was (459±1402) μg/kg at bolus and (012±005) μg/(kg·min) as maintenance.The survival analysis of filters life suggested an increasing after LMWH replaced by argatroban (median filter life 140h vs 480h,P＜0001).And no statistical changes in coagulation status (including APTT、Fg、ATⅢ and Ddimer) after the replacement of anticoagulant.Meanwhile,WBC and PLT were decreased slightly but statistical significantly.No bleeding events and liver function (DBIL,IBIL,ALT and AST) abnormal were recorded by follow up to 72h after the end of CRRT，or to censored.
Ｃｏｎｃｌｕｓｉｏｎ：
The low dose of argatroban combined with citrate will be an appropriate choice to replace LMWH combined with citrate as routine anticoagulation protocal in CRRT.

Key words: argatroban, low molecular weight heparin, regional citrate anticoagulation, continuous renal replacement therapy

李川，何旭，王泰娜，等. 小剂量阿加曲班联合枸橼酸体外抗凝的疗效[J]. 肾脏病与透析肾移植杂志, 2018, 27(4): 331-335.

LI Chuan,HE Xu,WANG Taina，et al. Effect and safety of low dose argatroban plus regional citrate anticoagulation in extracorporeal circulation[J]. Chinese Journal of Nephrology, Dialysis & Transplantation, 2018, 27(4): 331-335.

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ISSN 1006-298X CN 32-1425/R

小剂量阿加曲班联合枸橼酸体外抗凝的疗效

Effect and safety of low dose argatroban plus regional citrate anticoagulation in extracorporeal circulation

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