Ziai Farzad, Benesch Thomas, Kodras Katharina, Neumann Irmgard, Dimopoulos-Xicki Lida, Haas Martin
Department of Internal Medicine III, Division of Nephrology and Dialysis, University Hospital Vienna, Vienna, Austria.
Kidney Int. 2005 Aug;68(2):862-6. doi: 10.1111/j.1523-1755.2005.00468.x.
Between 5% and 10% of hemodialysis patients are treated with oral anticoagulants. It is currently unknown whether additional anticoagulation with heparin or low-molecular-weight heparin (LMWH) is needed to prevent clotting during hemodialysis.
In this prospective, randomized, cross-over study 10 patients treated with oral anticoagulants (phenprocoumon) received either no additional anticoagulation or low dose dalteparin (bolus of 40 IU/kg body weight) before dialysis. Efficacy of hemodialysis was measured by normalized weekly Kt/V and urea reduction rate (URR). Thrombus formation was evaluated by measurement of D-dimer and inspection of air traps and dialyser.
The median international normalized ratio (INR) did not differ between both observation periods (phenprocoumon 2.2(2 to 3) vs. dalteparin 2.1(2 to 2.9). The anti-Xa level in dalteparin patients was 0.33 (0.27 to 0.38) IU/mL after 2 hours and 0.16 (0.03 to 0.23) IU/mL after 4 hours of hemodialysis. The median increase of D-dimer was significantly higher in patients without additional dalteparin therapy during hemodialysis (DeltaD-dimer 0.23 microg/mL vs. 0.03 mug/mL) (P= 0.0004). Complete thrombosis of the dialyser membrane occurred in one patient in the phenprocoumon group but in none with combined treatment. The extent of thrombosis in the arterial and venous air trap and dialyser was significantly less in patients with additional dalteparin therapy (P= 0.0014, P= 0.0002, and P= 0.0005, respectively). Weekly Kt/V and URR was similar in both groups.
Standard oral anticoagulation with an INR between 2 and 3 is insufficient to prevent clotting during hemodialysis. Additional low dose anticoagulation with a LMWH or heparin is necessary to facilitate treatment.
5%至10%的血液透析患者接受口服抗凝剂治疗。目前尚不清楚在血液透析期间是否需要额外使用肝素或低分子肝素（LMWH）进行抗凝以防止凝血。
在这项前瞻性、随机、交叉研究中，10名接受口服抗凝剂（苯丙香豆素）治疗的患者在透析前要么不接受额外抗凝，要么接受低剂量达肝素（40 IU/kg体重推注）。通过标准化的每周Kt/V和尿素清除率（URR）来衡量血液透析的效果。通过测量D-二聚体以及检查空气捕捉器和透析器来评估血栓形成情况。
两个观察期的国际标准化比值（INR）中位数无差异（苯丙香豆素组为2.2（2至3），达肝素组为2.1（2至2.9））。达肝素组患者在血液透析2小时后的抗Xa水平为0.33（0.27至0.38）IU/mL，4小时后为0.16（0.03至0.23）IU/mL。在血液透析期间未接受额外达肝素治疗的患者中，D-二聚体的中位数升高显著更高（D-二聚体变化量为0.23μg/mL对0.03μg/mL）（P = 0.0004）。苯丙香豆素组有1名患者出现透析器膜完全血栓形成，而联合治疗组无此情况。在接受额外达肝素治疗的患者中，动脉和静脉空气捕捉器及透析器中的血栓形成程度显著更低（分别为P = 0.0014、P = 0.0002和P = 0.0005）。两组的每周Kt/V和URR相似。
国际标准化比值（INR）在2至3之间的标准口服抗凝不足以防止血液透析期间的凝血。需要额外使用低剂量的低分子肝素或肝素进行抗凝以促进治疗。
