Hemostasis and Thrombosis in Continuous Renal Replacement Treatment
Hemostasis and Thrombosis in Continuous Renal Replacement Treatment
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DOI：
10.1055/s-0034-1398384
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发表时间：
2015-02-01
影响因子：
5.7
通讯作者：
Oudemans-van Straaten, Heleen M.
中科院分区：
文献类型：
--
作者：
Oudemans-van Straaten, Heleen M.
在连续性肾脏替代治疗期间，止血的微妙平衡被打破。由于危重病、尿毒症、体外循环和抗凝治疗的复杂相互作用，患者表现出高凝状态和出血风险增加。血液与异物的接触通过触发接触活化凝血途径、组织因子-因子VIIa途径以及粘附在膜上的血小板和单核细胞的活化来启动凝血。与危重病诱导的改变的相互作用进一步增强凝血和炎症。凝血、凝血酶原时间和活化凝血活酶时间以及血小板计数的经典标志物不能检测促凝血状态。重症患者的出血风险也会增加，用于回路凝血的抗凝剂会增加这种风险。肝素是最常用的。肝素会增加出血的风险。其疗效和安全性进一步受到抗凝血酶缺乏症、肝素与急性期蛋白和凋亡及坏死细胞的结合以及其对炎症的不可预测的影响的影响。因此，在危重病期间，其对抗凝的干扰是不可靠的。柠檬酸盐可提供局部抗凝作用并增加生物相容性。它比肝素耐受性更好，出血更少，输血更少，回路寿命更长。
During continuous renal replacement therapy, the delicate equilibrium of hemostasis is disturbed. Owing to a complex interaction of critical illness, uremia, use of an extracorporeal circuit and anticoagulation, patients exhibit both hypercoagulability and an increased risk of bleeding. Contact of blood with foreign material initiates coagulation by triggering the contact activation coagulation pathway, the tissue factor-factor VIIa pathway and activation of platelets and monocytes, which adhere to the membrane. The interaction with critical illness induced alterations further enhances coagulation and inflammation. Classical markers of coagulation, prothrombin and activated thromboplastin time, and platelet count do not detect the procoagulant state. Critically ill patients also have in increased risk of bleeding and anticoagulation used for circuit clotting enhances this risk. Heparin is most commonly used. Heparin increases the risk of bleeding. Its efficacy and safety are further compromised by antithrombin deficiency, heparin binding to acute phase proteins and apoptotic and necrotic cells, and by its unpredictable effects on inflammation. Its interference with anticoagulation is therefore unreliable during critical illness. Citrate provides regional anticoagulation and increases biocompatibility. It is better tolerated than heparin and confers less bleeding, less transfusion, and longer circuit life.