Davenport A
University College London Centre for Nephrology, Royal Free Hospital, London, UK.
Minerva Urol Nefrol. 2006 Jun;58(2):171-80.
Anticoagulation of the extracorporeal circuit, once a major technical problem that delayed the development of chronic intermittent haemodialysis, is today largely taken for granted as part of normal routine practice. The initiation of coagulation in the extracorporeal hemodialysis circuit is a manifestation of bioincompatibility, due to the activation of leukocytes, platelets and the coagulation cascades, rather than simple contact of intrinsic system coagulation proteins which the dialyser surface and plastic tubing leading to activation of the contact coagulation cascade. Although unfractionated heparin remains the most commonly used anticoagulant world wide, low molecular weight heparin offers the advantage of more reliable pharmacokinetics, allowing the use of a simple single bolus, with less dialyser fouling, and perhaps more importantly, less osteoporosis, hyperkalemia and abnormal lipoprotein profile. Although regional anticoagulants are available and offer the advantage of reducing the risk of haemorrhage, these tend to be prohibitively expensive, or require increased complexity such as citrate. Unfortunately the incidence of immune mediated heparin induced thrombocytopenia appears to be increasing, and these patients require systemic anticoagulation with the direct thrombin inhibitors and/or heparinoids to prevent thrombosis.
体外循环的抗凝，曾经是一个严重阻碍慢性间歇性血液透析发展的技术问题，如今在很大程度上已被视为正常常规操作的一部分而被视为理所当然。体外血液透析回路中凝血的启动是生物不相容性的一种表现，这是由于白细胞、血小板和凝血级联反应的激活，而不是透析器表面和塑料管路导致内源性系统凝血蛋白简单接触从而激活接触凝血级联反应。尽管普通肝素仍然是全球最常用的抗凝剂，但低分子量肝素具有药代动力学更可靠的优势，允许使用简单的单次推注，透析器污染更少，也许更重要的是，骨质疏松、高钾血症和脂蛋白异常的发生率更低。尽管有局部抗凝剂可供使用，且具有降低出血风险的优势，但这些往往价格高得令人望而却步，或者需要增加复杂性，如使用柠檬酸盐。不幸的是，免疫介导的肝素诱导的血小板减少症的发生率似乎在增加，这些患者需要使用直接凝血酶抑制剂和/或类肝素进行全身抗凝以预防血栓形成。
