低剂量两段法枸橼酸抗凝血液透析的 临床疗效观察

目的 观察低剂量两段法局部枸橼酸抗凝对高危出血风险患者行含钙透析液血液透析的有效性 和安全性。方法 选取2017 年1 月—2018 年12 月于解放军联勤部保障部队第940 医院血液净化中心行维 持性血液透析的患者83 例，将患者分为常规剂量组和低剂量组。常规剂量组设定前段4% 枸橼酸钠溶液输注 量为血流量的1.5 倍；低剂量组设定4% 枸橼酸钠溶液输注量为血流量的1.0 倍。两组均使用标准含钙透析 液，且不在静脉回路补充钙剂。比较两组患者一般资料、血液透析指标、抗凝有效率及单次透析Kt/V 情况。 结果 低剂量组透析器前4% 枸橼酸溶液输注量较常规剂量组低（P <0.05），静脉壶4% 枸橼酸溶液输注量较常 规剂量组高（P <0.05）。低剂量组透析器、静脉壶凝血有效率较常规剂量组高（P <0.05）。低剂量组实际血流量 较常规剂量组高（P <0.05），低剂量组单次透析Kt/V 较常规剂量组低（P <0.05）。低剂量组患者未出现口周麻木、 肌肉抽搐等异常情况。结论 对于高危出血风险的血液透析患者，低剂量两段法局部枸橼酸抗凝是有效且安全 的，且由于血流量较常规剂量局部枸橼酸抗凝增加，透析充分性明显提高，值得进一步临床推广。

Clinical investigation of low-dose and two-stage citrate anticoagulation in hemodialysis

Objective To observe the efficacy and safety of low-dose two-stage regional citrate anticoagulation (RCA) in hemodialysis with calcium-containing dialysate in patients with high risk of bleeding. Methods The patients undergoing maintenance hemodialysis with high risk of bleeding and meeting criteria for citrate anticoagulation were divided into two groups. The ratio of blood flow to volume of infused 4% sodium citrate was 1:1.5 in the regular-dose two-stge RCA group (regular-dose group), while that was 1:1.0 in the low-dose twostge RCA group (low-dose group). 4% citrate anticoagulation solution was infused both prior to dialyzer and at venous bubble trap. Standard calcium-containing dialysate was used in both regular-dose and low-dose group, and calcium was not supplemented in venous circuit. Demographic data, clinical indicators of hemodialysis, efficacy of anticoagulation and single-session Kt/V were observed regularly during the treatment. The above parameters were compared between the regular-dose group and the low-dose group. Results A total of 303 hemodialysis sessions in 83 patients were included, of which 180 hemodialysis sessions were treated by regular-dose RCA, where the effective blood flow was 150 ml/min, dialysate volume was 300 ml/min, and mean volume of 4% sodium citrate was (225.6±14.2) ml/h prior to dialyzer and (18.5±3.3) ml/h at venous bubble trap. For the other 123 hemodialysis sessions treated by low-dose RCA, the effective blood volume was 200 ml/min, dialysate volume was 500 ml/min,and mean volume of 4% sodium citrate was (200.6±10.4) ml/h prior to dialyzer and (20.5±3.2) ml/h at venous bubble trap. When comparing the two groups, there were significant differences in the effective rate of anticoagulation in both cases of infusion prior to dialyzer (97.3% VS 100.0%, P < 0.05) and at venous bubble trap (96.8% VS 100.0%, P < 0.05). Furthermore, the single-session Kt/V of regular-dose group was significantly higher than that of the the low-dose group (1.0±0.2 VS 0.8±0.1, P < 0.05). Conclusions Low-dose two-stage RCA is an effective and safe anticoagulation option for hemodialysis patients with high risk of bleeding. Relatively, low-dose RCA is superior to regular-dose RCA in the dialysis sufficiency with higher blood flow, and can be widely used for hemodialysis in clinical practice.