CAJ | 학술논문

目的探讨血液透析(HD)患者应用普通肝素(UFH)和低分子量肝素(LMWH)的合理剂量.方法选取38例HD患者,随机分为4个治疗组,给予6种抗凝方法.小剂量UFH组(10例):uFH首剂35 U/kg,追加10U·kg~(-1)·h~(-1);小剂量UFH+预冲组:病例和UFH剂量同小剂量UFH组,并HD前给予40 mg/L肝素生理盐水预冲;大剂量UFH组(10例):UFH首剂55 U/kg,追加16 U·kg~(-1).h~(-1);小剂量LMWH组(10例):透析前30 min法安明60 U/kg(3500 U)静脉注射;小剂量LMWH+预冲组:病例和LMWH剂量同小剂量LMWH组,并HD前给40 mg/L肝素生理盐水预冲;大剂量LMWH组(8例):透析前30 min法安明80 U/kg(5000 U)静脉注射.分别在透析前管路动脉端、透析2 h管路动脉端和静脉端、透析结束管路动脉端采血,利用Sconoclot血凝分析仪测试玻璃珠活化凝血时间(gbACT)值、凝结速率(CR)值和血小板功能(PF)值.结果 (1)小剂量UFH组和小剂量UFH+预冲组:与HD前比较,HD 2 h的动脉端和静脉端的gbACT值均明显延长、CR值明显减少,HD结束后gbACT值和CR值无明显变化;但2组间各个时点的各种检测指标无明显差别.(2)小剂量LMWH组:各个时点的gbACT值无明显差别;与HD前比较,CR值在HD 2 h的动脉端和静脉端均明显减少,但HD结束后无明显变化.(3)小剂量LMWH+预冲组:与HD前比较,gbACT值HD 2 h动脉端明显延长,但HD 2 h静脉端和HD结束无明显变化;CR值HD 2 h的动脉端和静脉端均较小剂量LMWH组进一步减少,但HD结束后恢复至透析前水平.(4)大剂量UFH组和大剂量LMWH组:与HD前比较,在HD 2 h的动脉端和静脉端以及HD结束,gbACT值均明显延长,CR值明显减少.结论小剂量UFH抗凝效果充分、且不增加出血风险;小剂量LMWH可达到一定的抗凝效果;大剂量UFH和LMWH可引起出血风险;40 mg/L肝素生理盐水预冲增加小剂量LMWH抗凝效果,但也增加HD过程中的出血风险.
목적 탐토혈액투석(HD)환자응용보통간소(UFH)화저분자량간소(LMWH)적합리제량.방법 선취38례HD환자,수궤분위4개치료조,급여6충항응방법.소제량UFH조(10례):uFH수제35 U/kg,추가10U·kg~(-1)·h~(-1);소제량UFH+예충조:병례화UFH제량동소제량UFH조,병HD전급여40 mg/L간소생리염수예충;대제량UFH조(10례):UFH수제55 U/kg,추가16 U·kg~(-1).h~(-1);소제량LMWH조(10례):투석전30 min법안명60 U/kg(3500 U)정맥주사;소제량LMWH+예충조:병례화LMWH제량동소제량LMWH조,병HD전급40 mg/L간소생리염수예충;대제량LMWH조(8례):투석전30 min법안명80 U/kg(5000 U)정맥주사.분별재투석전관로동맥단、투석2 h관로동맥단화정맥단、투석결속관로동맥단채혈,이용Sconoclot혈응분석의측시파리주활화응혈시간(gbACT)치、응결속솔(CR)치화혈소판공능(PF)치.결과 (1)소제량UFH조화소제량UFH+예충조:여HD전비교,HD 2 h적동맥단화정맥단적gbACT치균명현연장、CR치명현감소,HD결속후gbACT치화CR치무명현변화;단2조간각개시점적각충검측지표무명현차별.(2)소제량LMWH조:각개시점적gbACT치무명현차별;여HD전비교,CR치재HD 2 h적동맥단화정맥단균명현감소,단HD결속후무명현변화.(3)소제량LMWH+예충조:여HD전비교,gbACT치HD 2 h동맥단명현연장,단HD 2 h정맥단화HD결속무명현변화;CR치HD 2 h적동맥단화정맥단균교소제량LMWH조진일보감소,단HD결속후회복지투석전수평.(4)대제량UFH조화대제량LMWH조:여HD전비교,재HD 2 h적동맥단화정맥단이급HD결속,gbACT치균명현연장,CR치명현감소.결론 소제량UFH항응효과충분、차불증가출혈풍험;소제량LMWH가체도일정적항응효과;대제량UFH화LMWH가인기출혈풍험;40 mg/L간소생리염수예충증가소제량LMWH항응효과,단야증가HD과정중적출혈풍험.
Objective To investigate the appropriate dose of unfraction heparin and low molecular weight heparin (LMWH) in hemodialysis patients. Methods Thirty-eight hemodialysis patients were enrolled and randomly allocated into four groups. The initial bolus dose for the Low-dose (LH, n = 10) and high-dose heparin (HH, n = 10) groups were 35 U/kg and 55 U/kg, respectively. The repeated maintenance dose for both groups were 10 U/kg·h and 16 U/kg·h, respectively. Fragmin were administered as single bolus (60 U/kg or 80 U/kg) at 30 minutes before hemodialysis in Low-dose LMWH (LLMWH, n = 10) and High-dose LMWH (HLMW,n=8) group, respectively. Furthermore, the dialysis circuits in LUFH and LLMWUFH groups were primed with with 4 mg/dl heparinized saline before hemodialysis. Glass bead active clotting time (gbACT), clot rate (CR)and platelet function (PF) were examined using Sonoclot analysator at 0 h ,2 h and the end of hemodialysis at the arterial circuit and 2 h at the venous circuit. Results (1) LH and LUFH: the increase of gbACT and decrease of CR at the arterial circuit and the venous circuit at 2 h of hemodialysis were significant compared with baseline. While they recovered at the end of hemodialysis. No difference between the two groups at different time points was found, either. (2)LLMWH:No change were found in gbACT during hemodialysis. CR at the arterial circuit and the venous circuit were significantly decreased at 2 h and recovered at the end of hemodialysis. (3) LI.MWUFH:gbACT at the arterial circuit was significantly increased only at 2 h of hemodialysis. CR at the arterial circuit and the venous circuit at 2 h of hemodialysis were significantly decreased and recovered when hemodialysis finished. (4) HH and HLMWH: gbACT were significantly increased and CR were rapidly decreased at both the arterial circuit and venous circuit at 2 h of hemodialysis. Conclusion Low-dose heparin was effective and safe as anticoagulant in hemodialysis. Low-dose low-molecular-weight heparin was efficient in anticoagulation to some extent. However, High-dose low-molecular-weight heparin, high-dose heparin and flushing with heparinized saline may increase the risk of hemorrhage.