枸橼酸钠抗凝连续性肾脏替代治疗救治尿毒症脑出血患者的优势

doi:10.3969/j.issn.1004-583X.2021.05.008

摘要/Abstract

摘要：

目的探讨枸橼酸钠抗凝连续性肾脏替代治疗(continuous renal replacement therapy, CRRT)在救治尿毒症脑出血患者中的优势。方法 2012年1月至2020年6月尿毒症脑出血患者44例,根据抗凝方式分为枸橼酸钠抗凝CRRT组(n=17)和无肝素CRRT组(n=27),比较两组生存率及各指标之间的差异;根据结局事件分为生存组(n=34)和死亡组(n=10),比较、分析枸橼酸钠抗凝CRRT在救治尿毒症脑出血患者中的价值。结果经过枸橼酸钠抗凝CRRT治疗的脑出血患者生存率为100.0%,而经过无肝素CRRT治疗的患者生存率为63.0%(χ²=8.148,P=0.004)。两组在血清钠、钙、钾、血小板计数、白细胞计数、C反应蛋白(CRP)、D-二聚体、甘油三酯方面差异有统计学意义。生存组B型钠尿肽、钙、CRP、D-二聚体、磷、白细胞计数较死亡组显著减低,而血清白蛋白、钠、血小板计数较死亡组显著升高。结论尿毒症患者脑出血发生后,枸橼酸钠抗凝CRRT治疗具有比无肝素CRRT治疗更为明显的优势,既能保证充分血液透析,又能改善尿毒症脑出血患者的低血钠、高血钙,减轻炎症状态,保证救治成功率。

关键词: 尿毒症, 脑出血, 连续性肾替代疗法, 抗凝药

Abstract:

Objective To explore the advantages of sodium citrate anticoagulationin continuous renal replacement therapy(CRRT) on uremic patients with cerebral hemorrhage. Methods Totally 44 uremic patients with cerebral hemorrhage who were rescued from January 2012 to June 2020, were divided into sodium citrate anticoagulationin CRRT group(n=17) and heparin-free CRRT group(n=27) according to different anticoagulation methods. The survival rate and related items were compared between two groups. The patients were also divided into survival group(n=34) and death group(n=10) according to different outcome events. The value of sodium citrate anticoagulation in CRRT for uremic patients with cerebral hemorrhage was analyzed. Results The survival rate in sodium citrate anticoagulationin CRRT group was(100%) significantly higher than in heparin-free group(63.0%) (χ²=8.148,P=0.004). There were statistically significant difference in serum sodium, calcium, potassium, platelet count, white blood cell count, C-reactive protein, D-dimer, triglycerides in sodium citrate anticoagulationin CRRT group and heparin-free CRRT group. Blood B-type natriuretic peptide, calcium, CRP, D-dimer, phosphorus, white blood cell count in surival group were reduced compared with death group, but albumin, sodium, and platelet count were increased significantly in survival group. Conclusion Sodium citrate anticoagulation showed obvious advantage compared with heparin-free in CRRT on uremic patients with cerebral hemorrhage and can not only ensure adequate dialysis, but also improve the hyponatremia and hypercalcemia and reduce inflammation with the higher success rate of treatment.

Key words: uremia, cerebral hemorrhage, continuous renal replacement therapy, anticoagulant drug

中图分类号:

R692.5

李文哲, 商进春, 李春梅, 李君, 田芬, 崔莉, 陈怿鹏, 张小凡, 邢广群. 枸橼酸钠抗凝连续性肾脏替代治疗救治尿毒症脑出血患者的优势[J]. 临床荟萃, 2021, 36(5): 425-431.

Li Wenzhe, Shang Jinchun, Li Chunmei, Li Jun, Tian Fen, Cui Li, Chen Yipeng, Zhang Xiaofan, Xing Guangqun. Effect of sodium citrate anticoagulation in continuous renal replacement therapy on uremic patients with cerebral hemorrhage[J]. Clinical Focus, 2021, 36(5): 425-431.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2021.05.008

https://huicui.hebmu.edu.cn/CN/Y2021/V36/I5/425

图/表 6

参考文献 21

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组别	例数	性别[例(%)]		年龄(岁)	既往高血压病史 [例(%)]	既往糖尿病史 [例(%)]	既往脑血管病史 [例(%)]	既往多囊肾病史 [例(%)]	脑出血前常规血液透析使用肝素/低分子肝素[例(%)]	日常使用华法林 [例(%)]	日常使用阿司匹林 [例(%)]
		男	女
		枸橼酸钠抗凝CRRT组	17									11(64.7)	6(35.2)	55.31±12.24	15(88.2)	6(35.3)	12(70.6)	2(11.8)	17(100)	7(41.2)	4(23.5)
无肝素CRRT组	27	15(55.6)	12(44.4)	55.15±13.62	26(96.3)	17(63.0)	20(74.1)	2(7.4)	27(100)	11(40.7)	8(29.6)
统计值		χ²= 0.361		t=-0.040	χ²=1.067	χ²=3.201	χ²=0.064	χ²=0.202	χ²=0.000	χ²=0.001	χ²=0.196
P值		>0.05		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

组别	例数	性别[例(%)]		年龄(岁)	既往高血压病史 [例(%)]	既往糖尿病史 [例(%)]	既往脑血管病史 [例(%)]	既往多囊肾病史 [例(%)]	脑出血前常规血液透析使用肝素/低分子肝素[例(%)]	日常使用华法林 [例(%)]	日常使用阿司匹林 [例(%)]
		男	女
		枸橼酸钠抗凝CRRT组	17									11(64.7)	6(35.2)	55.31±12.24	15(88.2)	6(35.3)	12(70.6)	2(11.8)	17(100)	7(41.2)	4(23.5)
无肝素CRRT组	27	15(55.6)	12(44.4)	55.15±13.62	26(96.3)	17(63.0)	20(74.1)	2(7.4)	27(100)	11(40.7)	8(29.6)
统计值		χ²= 0.361		t=-0.040	χ²=1.067	χ²=3.201	χ²=0.064	χ²=0.202	χ²=0.000	χ²=0.001	χ²=0.196
P值		>0.05		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

项目	枸橼酸钠抗凝CRRT组(n=17)	无肝素CRRT组(n=27)	Z值/χ²值	P值
出血量(ml)	31.690(15.549,39.061)	17.298(6.756,51.687)	-0.845	0.398
格拉斯哥评分(分)	10.000(4.000,15.000)	10.000(3.750,13.250)	-0.328	0.743
破入脑室[例(%)]	3(6.8)	2(4.6)	1.086	0.297
脑出血部位[例(%)]			4.475	0.929
基底节区	4(23.5)	8(29.6)	0.196	0.658
额顶颞枕叶	4(23.5)	7(25.9)	0.032	0.858
蛛网膜下腔	3(17.6)	3(11.1)	0.378	0.538
脑干	1(5.9)	4(14.8)	0.826	0.363
丘脑	2(11.8)	2(7.4)	0.240	0624
放射冠区	1(5.9)	1(3.7)	0.114	0.736
小脑	1(5.9)	1(3.7)	0.114	0.735
硬膜下血肿	0	1(3.7)	0.644	0.422
脑室旁	1(5.9)	0	1.625	0.202

项目	枸橼酸钠抗凝CRRT组(n=17)	无肝素CRRT组(n=27)	Z值/χ²值	P值
出血量(ml)	31.690(15.549,39.061)	17.298(6.756,51.687)	-0.845	0.398
格拉斯哥评分(分)	10.000(4.000,15.000)	10.000(3.750,13.250)	-0.328	0.743
破入脑室[例(%)]	3(6.8)	2(4.6)	1.086	0.297
脑出血部位[例(%)]			4.475	0.929
基底节区	4(23.5)	8(29.6)	0.196	0.658
额顶颞枕叶	4(23.5)	7(25.9)	0.032	0.858
蛛网膜下腔	3(17.6)	3(11.1)	0.378	0.538
脑干	1(5.9)	4(14.8)	0.826	0.363
丘脑	2(11.8)	2(7.4)	0.240	0624
放射冠区	1(5.9)	1(3.7)	0.114	0.736
小脑	1(5.9)	1(3.7)	0.114	0.735
硬膜下血肿	0	1(3.7)	0.644	0.422
脑室旁	1(5.9)	0	1.625	0.202

组别	例数	钠(mmol/L)								钙(mmol/L)											磷(mmol/L)
组别	例数	治疗前			治疗后					治疗前					治疗后						治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	135.725±6.064			141.289±3.382					2.217±0.218					2.155±0.219						1.460(1.345, 2.315)							1.745(1.485, 2.103)
无肝素CRRT组	27	138.548±4.678			138.415±4.061					2.082±0.293					2.438±0.296						1.560(1.320, 2.230)							1.960(1.530, 2.420)
统计值		t=-1.712			t=2.466					t=0.163					t=-3.603						Z=-0.274							Z=-1.299
P值		0.095			0.018					0.103					0.001						0.784							0.194
组别	例数	钾(mmol/L)						血肌酐(μmol/L)												尿素氮(mmol/L)
组别	例数	治疗前	治疗后					治疗前					治疗后							治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	4.908±0.987	4.327±0.507					821.050±337.104					570.378±186.234							25.205(16.800, 34.013)							21.310(14.590,28.183)
无肝素CRRT组	27	4.706±0.703	4.771±0.643					635.562±309.111					698.715±337.762							22.560(15.815, 36.775)							21.135(17.460,33.510)
统计值		t=-0.756	t=-2.445					t=1.793					t=-1.462							Z=-0.428							Z=-1.098
P值		0.454	0.019					0.081					0.151							0.669							0.272
组别	例数	ALT(U/L)							AST(U/L)																白蛋白(g/L)
组别	例数	治疗前		治疗后					治疗前								治疗后								治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	16.119±2.611		20.069±2.362					13.300(9.350, 15.700)								15.750(12.275,23.923)								35.994±5.104							35.006±4.868
无肝素CRRT组	27	14.676±1.484		24.402±4.285					15.200(11.650, 21.625)								18.700(12.150,25.375)								32.610±6.642							31.339±7.922
统计值		t=0.516		t=-0.784					Z=-1.657								Z=-0.418								t=1.724							t=1.899
P值		0.609		0.437					0.098								0.676								0.093							0.065
组别	例数	总蛋白(g/L)										甘油三酯(mmol/L)										总胆固醇(mmol/L)
组别	例数	治疗前					治疗后					治疗前						治疗后				治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	60.150(53.550, 67.050)					60.500(57.675,64.025)					2.270±0.439						1.391±0.604				4.080(3.533, 4.258)							4.110(3.223,5.193)
无肝素CRRT组	27	61.215(52.325, 67.775)					62.550(58.300,69.200)					2.480±0.338						2.215±1.060				4.585(3.743, 5.335)							3.990(3.775,4.380)
统计值		Z=0.041					Z=-1.386					t=-0.382						t=-3.206				Z=0.594							Z=-0.084
P值		0.967					0.166					0.704						0.003				0.553							0.993
组别	例数	LDL-C(mmol/L)						HDL-C(mmol/L)													血糖(mmol/L)
组别	例数	治疗前	治疗后					治疗前						治疗后							治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	2.501±0.717	2.632±0.873					1.160(0.890, 1.283)						1.120(0.890,1.535)							5.660(4.415, 8.783)							7.755(4.790,10.190)
无肝素CRRT组	27	2.658±1.028	2.523±0.824					1.180(1.010, 1.280)						1.085(0.943,1.275)							6.010(5.183, 7.795)							6.340(5.323,8.295)
统计值		t=-0.530	t=0.415					Z=-0.360						Z=-0.842							Z=-0.152							Z=-0.776
P值		0.599	0.680					0.719						0.400							0.879							0.438
组别	例数	DD(μg/L)									CRP(mg/L)													白细胞计数(×10⁹/L)
组别	例数	治疗前				治疗后					治疗前								治疗后					治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	580.000 (265.000, 1180.000)				450.000 (317.500,542.500)					6.430 (2.245, 19.760)								2.030 (0.500,7.750)					6.010 (5.285, 8.960)							5.975 (4.513,7.308)
无肝素CRRT组	27	850.000 (530.000, 1222.000)				845.000 (405.000,1360.000)					9.670 (1.770, 38.270)								14.920 (1.323,41.463)					7.895 (6.248, 10.095)							7.410 (6.633,8.623)
统计值		Z=-1.290				Z=-2.244					Z=-0.145								Z=-2.784					Z=-1.354							Z=-2.313
P值		0.197				0.025					0.885								0.005					0.176							0.021
组别	例数	血小板计数(×10⁹/L)								血红蛋白(g/L)													尿酸(μmol/L)
组别	例数	治疗前			治疗后					治疗前						治疗后							治疗前							治疗后
枸橼酸钠抗凝CRRT组	17	170.130±60.650			193.00±59.754					100.310±22.123						97.940±18.580							414.944±102.891							362.513±98.781
无肝素CRRT组	27	183.540±71.768			148.92±63.082					97.580±23.204						91.310±21.346							397.808±118.975							384.042±165.014
统计值		t=-0.615			t=2.292					t=0.371						t=1.068							t=0.470							t=-0.515
P值		0.542			0.027					0.713						0.292							0.641							0.609
组别	例数	PTH(pmol/L)														BNP(pg/ml)
组别	例数	治疗前						治疗后								治疗前										治疗后
枸橼酸钠抗凝CRRT组	17	204.350(90.005, 281.625)						210.650(148.475,519.975)								1454.850(393.600, 3978.750)										265.200(102.475, 627.600)
无肝素CRRT组	27	199.100(137.200, 334.500)						195.960(118.300,526.400)								375.050(144, 325, 804.325)										617.300(195.400, 930.900)
统计值		Z=-0.675						Z=-0.605								Z=-2.620										Z=-1.313
P值		0.511						0.545								0.009										0.189