抗Xa因子活性测定在长期血液透析老年患者的应用

发布时间：2018-06-06 12:10

本文选题：抗Xa + 因子　；参考：《苏州大学》2014年硕士论文

【摘要】：目的通过监测长期血液透析老年患者透析过程中抗Xa因子活性评估低分子肝素及普通肝素抗凝治疗的疗效。方法1：对静脉规律给予低分子肝素及普通肝素长期血液透析老年患者各24例，在给药开始后1h,2h,3h,4h,24h不同时间点采用发色底物法测定的抗X a因子活性,明确低分子肝素和普通肝素在老年患者所测抗X a因子活性达最高的时间点。2：选择规律使用低分子肝素的长期血液透析老年患者95例为甲组，规律使用普通肝素抗凝的长期血液透析老年患者40例为乙组：检测二组老年患者的抗X a因子活性，KT/V值，，HS-C反应蛋白，血清白蛋白(Alb)、前白蛋白（PAB）、血红蛋白(HGB)，血浆总胆固醇（TC）、甘油三脂（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL），Ca、P、K、碱性磷酸酶（ALP）;血细胞分析仪：血小板计数(PLT)、血小板比积(PCT)、平均血小板体积(MPV)、血小板分布宽度(PDW)；放免法测定:甲状旁腺激素（PTH），β2-微球蛋白（β2-MG），出血情况及SF-36健康调查量表进行生活质量评分作为比较，分析那种抗凝药物更适合长期血液透析的老年患者。3：根据抗Xa因子活性大小对95例规律使用低分子肝素长期血液透析老年患者分组其中：A组30例（抗Xa因子活性＜0.4IU/ml）, B组45例（0.4IU/ml≤抗Xa因子活性＜1.0IU/ml），C组20例（抗Xa因子活性≥1.0IU/ml）；检测各组长期使用低分子肝素血液透析的老年患者的KT/V,血红蛋白(HGB)、血浆白蛋白(ALB)、HS-CRP，总胆固醇(TC)、甘油三脂(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C),血清钙（Ca）及磷（P）、PTH(放免法测定)，出血情况及SF-36健康调查量表进行生活质量评分作为比较，分析低分子肝素在老年血液透析患者中的最适合的抗凝范围。结果1.长期血液透析的老年患者静脉给予低分子肝素组和普通肝素组的抗Xa因子活性2小时达到最高值，分别为（0.81±0.34）IU/ml和（0.96±0.41）IU/ml，静脉给药后4小时分别为(0.50±0.18）IU/ml和(0.5±0.09）IU/ml。 2.低分子肝素组与普通肝素组老年患者抗Xa因子活性分别为（0.6430.583）IU/ml、（0.5500.273）IU/ml，二组比较无统计学意义；二组的KT/V值分别为（1.38 0.390），（1.350.43），二组比较P＞0.05，无统计学意义。β2-MG在低分子肝素组为（30.239.87）mg/L，普通肝素组为（36.583.90）mg/L,P值为0.94。低分子肝素组的老年患者高敏C反应蛋白为(3.79±4.78)；普通肝素组的老年患者的高敏C反应蛋白为（6.998±1.566)，P＜0.05。低分子肝素组和普通肝素的血红蛋白、血清白蛋白及前白蛋白都在正常范围，二组比较无统计学意义。对于二组老年患者的血浆总胆固醇（TC）、甘油三脂（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL），低分子肝素组为：（4.62±0.54）mmol/L、（1.62±0.34）mmol/L、（1.51±0.32）mmol/L、（2.34±0.51）mmol/L；普通肝素为（4.97±0.65）mmol/L、（2.37±0.52）mmol/L、（1.06±0.34）mmol/L、（3.52±0.26）mmol/L，二组比较均P＜0.05，有统计学意义。低分子肝素组和普通肝素组PTH分别（437.21729.44）pg/ml和（183.73159.45）pg/ml；ALP（128.1085.87）mmo/L和（97.3320.75）mmo/L；两组比较无意义，但均大于正常上限。在低分子肝素组中血P高于正常范围，但与普通肝素比较无统计学意义。Ca、K均在正常范围内。低分子肝素组血小板计数：160.70±45.30；普通肝素组血小板计数：155.0±36.0，比较无统计学意义，其中二组老年患者血小板比积、平均血小板体积、血小板分布宽度比较P值均大于0.05。两组患者中低分子肝素组一共有6例患者出现透析后出血其中4例为轻度出血，2例为明显，出血人数占使用低分子肝素人数6.3%；普通肝素组出现5例轻度出血占使用普通肝素人数的12.5%。普通肝素组出血率是低分子肝素组的2倍，而且出血的患者抗Xa因子活性均大于1.0IU/ml。低分子肝素组SF-36生活质量评分中生理功能、生理职能、社会功能、情感职能得分为（83.4512.36）（86.788.07）（62.139.34）（86.3713.39）；普通肝素组中SF-36生活质量评分中相应项目的得分为（75.4310.36）（81.405.65）（59.467.08）（82.3115.53）；可以看出低分子肝素组得分均高于普通肝素组，但二组比较无统计学意义。躯体疼痛评估得分中低分子肝素组为（61.5811.4），低于普通肝素组得分（72.318.49），P二组比较均P＜0.05，有统计学意义。 3.进一步分析使用低分子肝素抗凝治疗的老年患者，以抗Xa因子活性＜ 0.4IU/ml（A组），以0.4IU/ml≤抗Xa因子活性＜1.0IU/ml（B组），抗Xa因子活性≥1.0IU/ml（C组）；其中A组KT/V值为1.100.08； B组KT/V值为1.450.22， C组KT/V值为1.320.16，B组和C组的KT/V值高于A组（P＜0.05），B组与C组的KT/V值，二组比较无统计学意义。抗Xa因子活性＜1.0IU/ml的老年患者（A组和B组）均无出血。但在使用低分子肝素组抗Xa因子活性±1.0IU/ml的20例老年患者中有鼻衄、瘀斑或穿刺部位血肿的轻度出血患者4例，出现全身瘀斑伴静脉穿刺点出血的患者1例。低分子肝素抗凝治疗的老年患者血红蛋白含量B组（128.4512.82）g/L高于A组(98.576.43)g/L和C组（105.7910.54）g/L（P＜0.05），但A组与C组的血红蛋白含量，二组比较无统计学意义。血清白蛋白分别为A组（37.032.36）g/L、B组（42.033.17）g/L、C组（36.915.39）g/L，B组高于A和C组（P＜0.05）,A组与C组的血清白蛋白，二组比较无统计学意义。三组中HS-CRP数值比较无统计学意义，但抗Xa因子活性±1.0IU/ml老年患者HS-CRP高于正常值上限。使用低分子肝素的长期血液透析的老年患者三组中血浆总胆固醇（TC）、甘油三脂(TG)、高密度脂蛋白(HDL)和低密度脂蛋白(LDL)，两两比较均无统计学意义。同时三组中血钙、血磷及血PTH浓度无统计学差异，其中血磷及PTH均高于正常上限值。相关分析显示抗Xa因子活性与KT/V、ALB、HGB呈正相关，与PTH呈负相关。对于使用低分子肝素长期血液透析的老年患者其中抗Xa因子活性≥0.4IU/ml的老年患者中SF-36健康调查量表各项生活质量评分中生理功能、活力、社会功能、精神健康得分高于抗Xa因子活性＜0.4IU/ml（A组），即B组、C组与A组比较，P＜0.05。结论 1.长期血液透析老年患者静脉给予常规剂量低分子肝素和普通肝素后2小时抗Xa因子活性均为最高，因此检测老年患者抗Xa因子活性的时间点应在静脉给药后2小时。 2.长期血液透析老年患者使用低分子肝素和普通肝素的抗凝效果是相似的。 3.有效剂量的低分子肝素及普通肝素均可以使老年血透患者达到充分透析，两者治疗效果相似。 4.使用低分子肝素抗凝治疗的老年血透患者生活质量高于使用普通肝素的老年血透患者。 5.将使用低分子肝素抗凝治疗的长期血透的老年患者的抗Xa因子活性维持在0.4IU/ml-1.0IU/ml的范围安全有效。 6.对于经济条件不好的老年患者可以选普通肝素，但低分子肝素对于长期血液透析的老年患者可以改善血脂、炎症状态，其出血副作用小，更值得推荐。
[Abstract]:Objective to evaluate the efficacy of low molecular weight heparin and unfractionated heparin anticoagulation in monitoring the anti Xa activity in elderly hemodialysis patients.
Method 1: 24 cases of low molecular weight heparin and ordinary heparin were given to the elderly patients with long-term hemodialysis. The anti X a factor activity of 1H, 2h, 3h, 4h, 24h was measured at different time points after the administration, and the highest time point of the anti X a factor activity of low molecular weight heparin and ordinary heparin in the elderly patients was found to be the highest time point.2: 95 long term hemodialysis elderly patients with low molecular weight heparin were selected as group a. 40 elderly patients with long-term hemodialysis with regular heparin anticoagulant were treated as group B. The anti X a factor activity, KT/V, HS-C reactive protein, serum albumin (Alb), prealbumin (PAB), hemoglobin (HGB), and plasma total in two groups of elderly patients were detected. Cholesterol (TC), glycerol three fat (TG), high density lipoprotein (HDL), low density lipoprotein (LDL), Ca, P, K, alkaline phosphatase (ALP); blood cell analyzer: platelet count (PLT), platelet specific product (PCT), average platelet volume (MPV), blood plate distribution width (PDW); radioimmunoassay: parathyroid hormone (beta), beta haemorrhage, bleeding The quality of life score was compared with the SF-36 health survey. The analysis of the anticoagulant drugs was more suitable for the elderly patients with long-term hemodialysis.3: according to the anti Xa factor activity, 95 regular use of low molecular weight heparin in the long-term hemodialysis elderly patients were grouped in 30 cases (anti Xa activity < 0.4IU/ml), and 45 cases in group B. (0.4IU/ml less than Xa factor activity < 1.0IU/ml), 20 cases in group C (anti Xa activity more than 1.0IU/ml); KT/V, hemoglobin (HGB), plasma albumin (ALB), HS-CRP, total cholesterol (TC), glycerol three fat (TG), low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol Alcohol (HDL-C), serum calcium (Ca) and phosphorus (P), PTH (radioimmunoassay), bleeding and SF-36 health survey scale were compared to analyze the most suitable anticoagulant range of low molecular weight heparin in the elderly hemodialysis patients.
Results 1. of the elderly patients with long-term hemodialysis, the anti Xa factor activity of the low molecular heparin group and the ordinary heparin group reached the highest value for 2 hours, respectively (0.81 + 0.34) IU/ml and (0.96 + 0.41) IU/ml respectively, and 4 hours after the intravenous administration were (0.50 + 0.18) IU/ml and (0.5 + 0.09) IU/ml. respectively.
The anti Xa factor activity of 2. low molecular weight heparin group and ordinary heparin group was (0.6430.583) IU/ml, (0.5500.273) IU/ml, respectively, and there was no statistical significance in the two group; the KT/V value of the two groups was 1.38, respectively (1.38).
0.390), (1.350.43), the two groups compared P > 0.05, no statistical significance. Beta 2-MG in the low molecular heparin group was (30.239.87) mg/L, the common heparin group was (36.583.90) mg/L, P value was 0.94..
The high sensitive C reactive protein of the elderly patients in the low molecular weight heparin group was (3.79 + 4.78), the high sensitive C reaction protein of the elderly patients in the normal heparin group was (6.998 + 1.566), the P < 0.05. low molecular weight heparin group and the hemoglobin of the ordinary heparin, the serum albumin and the prealbumin were normal, and the two groups were not statistically significant.
For two groups of elderly patients, the plasma total cholesterol (TC), glycerin three fat (TG), high density lipoprotein (HDL), low density lipoprotein (LDL), low molecular weight heparin group were (4.62 + 0.54) mmol/L, (1.62 + 0.34) mmol/L, (1.51 + 0.32) mmol/L, (2.34 + 0.51) mmol/L; ordinary heparin was (4.97 + 0.65) mmol/L, (2.37 + 0.52) mmol/L, mmol/L, mmol/L. 6) mmol/L, and the difference between the two groups was P < 0.05, which was statistically significant.
The PTH (437.21729.44) pg/ml and (183.73159.45) pg/ml, ALP (128.1085.87) mmo/L and (97.3320.75) mmo/L were respectively in the low molecular weight heparin group and the normal heparin group. The two groups were more meaningless but larger than the normal upper limit. In the low molecular weight heparin group, the blood P was higher than the normal range, but there was no significant.Ca in the normal heparin group.
The platelet count in the low molecular weight heparin group was 160.70 + 45.30, and the platelet count in the normal heparin group was 155 + 36, and there was no statistical significance. The P values of the platelet specific product, the average platelet volume and the distribution width of the platelets in the two groups of elderly patients were more than 0.05.
In the two groups, 6 cases of low molecular weight heparin group had hemodialysis hemorrhage, 4 cases were mild bleeding, 2 cases were obvious, the number of bleeding accounted for 6.3% of low molecular weight heparin, and 5 cases of ordinary heparin group had 5 cases of 12.5%. ordinary heparin group with low molecular weight heparin, and the bleeding rate was 2 times that of low molecular weight heparin group. The activity of anti Xa factor in patients with blood is greater than that of 1.0IU/ml.
The score of physiological function, physiological function, social function and emotional function was (83.4512.36) (86.788.07) (62.139.34) (86.3713.39) in the quality of life score of low molecular weight heparin group (SF-36). The score of the corresponding items in the quality score of SF-36 in the normal heparin group was (75.4310.36) (81.405.65) (59.467.08) (82.3115.53), and the low molecular weight heparin could be seen. The score of the group was higher than that of the normal heparin group, but there was no statistical significance in the two groups. The score of low molecular weight heparin in the score of somatic pain assessment was (61.5811.4), which was lower than that of the ordinary heparin group (72.318.49), and the comparison of the two groups in the P group was P < 0.05, with statistical significance.
3. further analysis of elderly patients with low molecular weight heparin anticoagulation with anti Xa factor activity <
Group 0.4IU/ml (group A), with 0.4IU/ml < Xa factor activity < 1.0IU/ml (B group), anti Xa factor.
The activity was more than 1.0IU/ml (group C), and the KT/V value of group A was 1.100.08, the KT/V value of group B was 1.450.22, C group KT/V value was 1.320.16, B group and group were higher than that of the group (< 0.05). The values of the group and the group were not statistically significant.
There were no bleeding in the elderly patients (group A and B) with anti Xa factor activity < 1.0IU/ml. But in 20 elderly patients with low molecular weight heparin anti Xa activity of + 1.0IU/ml, there were 4 patients with epistaxis, ecchymosis or puncture site hematoma, and 1 patients with systemic ecchymosis and venipuncture bleeding.
The hemoglobin content in group B (128.4512.82) g/L of the elderly patients with low molecular weight heparin was higher than that of group A (98.576.43) g/L and C group (105.7910.54) g/L (P < 0.05), but the hemoglobin content in A group and C group was not statistically significant. And group C (P < 0.05), the serum albumin of group A and C group was not statistically significant. There was no statistical significance in the number of HS-CRP in the three groups, but the HS-CRP of the elderly patients with anti Xa activity + 1.0IU/ml was higher than the upper limit of the normal value.
The total plasma cholesterol (TC), glycerin three fat (TG), high density lipoprotein (HDL) and low density lipoprotein (LDL) in the three groups of elderly patients with long-term hemodialysis with low molecular weight heparin were not statistically significant. There was no statistical difference between the three groups of blood calcium, blood phosphorus and blood PTH concentration, among which the blood phosphorus and PTH were higher than the normal upper limit.
Correlation analysis showed that the activity of anti Xa factor was positively correlated with KT/V, ALB and HGB, and negatively correlated with PTH.
For elderly patients with long-term hemodialysis with low molecular weight heparin, in the elderly patients with anti Xa factor activity more than 0.4IU/ml, the scores of physiological function, vitality, social function, and mental health were higher than those of anti Xa factor activity < 0.4IU/ml (group A), that is, B group, C group and A group, P < 0.05. in SF-36 health survey scale.
conclusion
1. in the elderly patients with long-term hemodialysis, the activity of anti Xa factor was the highest for 2 hours after intravenous administration of low molecular weight heparin and ordinary heparin, so the time point of detecting anti Xa factor activity in elderly patients should be 2 hours after intravenous administration.
2. the anticoagulant effect of low molecular weight heparin and unfractionated heparin is similar in elderly patients undergoing long-term hemodialysis.
3. effective dose of low molecular weight heparin and unfractionated heparin can make elderly hemodialysis patients achieve adequate dialysis.
4. the quality of life of elderly hemodialysis patients using low molecular weight heparin anticoagulant therapy is higher than that of elderly hemodialysis patients using ordinary heparin.
5. it is safe and effective to maintain the anti Xa factor activity in elderly patients with low molecular weight heparin anticoagulation therapy in the range of 0.4IU/ml-1.0IU/ml.
6. for elderly patients with poor economic conditions, ordinary heparin can be selected, but low molecular weight heparin can improve blood lipid, inflammatory state, and less side effects for the elderly patients with long-term hemodialysis, which are more worthy of recommendation.
【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.5

【参考文献】