摘要
Abstract
Objective To evaluate the effects of different extracorporeal anticoagulation strategies on circuit clotting control and bleeding safety in maintenance hemodialysis patients at high risk of bleeding,and to provide evidence for individu-alized anticoagulation management.Methods This prospective cohort study enrolled 62 maintenance hemodialysis patients at high bleeding risk from January 2022 to January 2025.According to the anticoagulation strategy used during dialysis,patients were assigned to a heparin-free group(n=21),a low-dose low-molecular-weight heparin(LMWH)group(n=20),and a region-al citrate anticoagulation(RCA)group(n=21).Changes in extracorporeal circuit pressure,dialyzer clotting grade,premature circuit clotting,coagulation activation biomarkers,and bleeding events were compared among the three groups.Results Base-line characteristics were comparable among the three groups(all P>0.05).The increase in transmembrane pressure(TMP)was significantly lower in the RCA group than in the low-dose LMWH and heparin-free groups[(18.7±6.4)mmHg vs.(27.9±9.7)mmHg and(41.3±12.8)mmHg,P<0.001].The incidence of premature circuit clotting decreased from the heparin-free group to the low-dose LMWH group and RCA group[38.10%(8/21),20.00%(4/20),and 9.52%(2/21),respectively;P=0.027 for trend].Post-dialysis levels of thrombomodulin,plasmin-α2-plasmin inhibitor complex,thrombin-antithrombin complex,and tissue-type plasminogen activator-inhibitor complex showed a graded pattern,with the lowest levels in the RCA group,intermediate levels in the low-dose LMWH group,and the highest levels in the heparin-free group,and the between-group differences were statis-tically significant(all P<0.05).A total of 16 bleeding events occurred,including 5 major bleeding events(8.06%),8 clinically relevant non-major bleeding(CRNMB)events(12.90%),and 3 minor bleeding events(4.84%).The rate of major bleeding did not differ significantly among the groups(P=0.829),whereas the incidence of CRNMB decreased from the heparin-free group to the low-dose LMWH group and RCA group(23.81%,15.00%,and 0%,respectively;P=0.021 for trend).Multivariate logistic regression showed that heparin-free dialysis(OR=2.88,95%CI:1.11-7.43,P=0.029)and TMP elevation(OR=1.07,95%CI:1.02-1.13,P=0.008)were independently associated with premature circuit clotting.Kaplan-Meier analysis indicated that the RCA group had the longest circuit patency time(P=0.014).Conclusion In maintenance hemodialysis patients at high risk of bleeding,RCA was more effective than heparin-free dialysis and low-dose LMWH in maintaining extracorporeal circuit patency,attenuating TMP elevation,and reducing premature circuit clotting,without increasing major bleeding events.Heparin-free dial-ysis avoided systemic anticoagulant exposure but was associated with a higher risk of circuit clotting,whereas low-dose LMWH showed an intermediate efficacy-safety profile.RCA may represent a safe and effective individualized anticoagulation strategy for this high-risk population.关键词
高出血风险/维持性血液透析/体外循环/局部枸橼酸抗凝/凝血状态/出血事件Key words
high bleeding risk/maintenance hemodialysis/extracorporeal circulation/regional citrate anticoagulation/coagulation status/bleeding events
