本文選題：抗Xa + 因子��； 參考：《蘇州大學》2014年碩士論文

【摘要】：目的通過監(jiān)測長期血液透析老年患者透析過程中抗Xa因子活性評估低分子肝素及普通肝素抗凝治療的療效。 方法1：對靜脈規(guī)律給予低分子肝素及普通肝素長期血液透析老年患者各24例，在給藥開始后1h,2h,3h,4h,24h不同時間點采用發(fā)色底物法測定的抗X a因子活性,明確低分子肝素和普通肝素在老年患者所測抗X a因子活性達最高的時間點。2：選擇規(guī)律使用低分子肝素的長期血液透析老年患者95例為甲組，規(guī)律使用普通肝素抗凝的長期血液透析老年患者40例為乙組：檢測二組老年患者的抗X a因子活性，KT/V值，，HS-C反應蛋白，血清白蛋白(Alb)、前白蛋白（PAB）、血紅蛋白(HGB)，血漿總膽固醇（TC）、甘油三脂（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL），Ca、P、K、堿性磷酸酶（ALP）;血細胞分析儀：血小板計數(shù)(PLT)、血小板比積(PCT)、平均血小板體積(MPV)、血小板分布寬度(PDW)；放免法測定:甲狀旁腺激素（PTH），β2-微球蛋白（β2-MG），出血情況及SF-36健康調(diào)查量表進行生活質(zhì)量評分作為比較，分析那種抗凝藥物更適合長期血液透析的老年患者。3：根據(jù)抗Xa因子活性大小對95例規(guī)律使用低分子肝素長期血液透析老年患者分組其中：A組30例（抗Xa因子活性＜0.4IU/ml）, B組45例（0.4IU/ml≤抗Xa因子活性＜1.0IU/ml），C組20例（抗Xa因子活性≥1.0IU/ml）；檢測各組長期使用低分子肝素血液透析的老年患者的KT/V,血紅蛋白(HGB)、血漿白蛋白(ALB)、HS-CRP，總膽固醇(TC)、甘油三脂(TG)、低密度脂蛋白膽固醇(LDL-C)、高密度脂蛋白膽固醇(HDL-C),血清鈣（Ca）及磷（P）、PTH(放免法測定)，出血情況及SF-36健康調(diào)查量表進行生活質(zhì)量評分作為比較，分析低分子肝素在老年血液透析患者中的最適合的抗凝范圍。 結(jié)果1.長期血液透析的老年患者靜脈給予低分子肝素組和普通肝素組的抗Xa因子活性2小時達到最高值，分別為（0.81±0.34）IU/ml和（0.96±0.41）IU/ml，靜脈給藥后4小時分別為(0.50±0.18）IU/ml和(0.5±0.09）IU/ml。 2.低分子肝素組與普通肝素組老年患者抗Xa因子活性分別為（0.6430.583）IU/ml、（0.5500.273）IU/ml，二組比較無統(tǒng)計學意義；二組的KT/V值分別為（1.38 0.390），（1.350.43），二組比較P＞0.05，無統(tǒng)計學意義。β2-MG在低分子肝素組為（30.239.87）mg/L，普通肝素組為（36.583.90）mg/L,P值為0.94。 低分子肝素組的老年患者高敏C反應蛋白為(3.79±4.78)；普通肝素組的老年患者的高敏C反應蛋白為（6.998±1.566)，P＜0.05。低分子肝素組和普通肝素的血紅蛋白、血清白蛋白及前白蛋白都在正常范圍，二組比較無統(tǒng)計學意義。 對于二組老年患者的血漿總膽固醇（TC）、甘油三脂（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL），低分子肝素組為：（4.62±0.54）mmol/L、（1.62±0.34）mmol/L、（1.51±0.32）mmol/L、（2.34±0.51）mmol/L；普通肝素為（4.97±0.65）mmol/L、（2.37±0.52）mmol/L、（1.06±0.34）mmol/L、（3.52±0.26）mmol/L，二組比較均P＜0.05，有統(tǒng)計學意義。 低分子肝素組和普通肝素組PTH分別（437.21729.44）pg/ml和（183.73159.45）pg/ml；ALP（128.1085.87）mmo/L和（97.3320.75）mmo/L；兩組比較無意義，但均大于正常上限。在低分子肝素組中血P高于正常范圍，但與普通肝素比較無統(tǒng)計學意義。Ca、K均在正常范圍內(nèi)。 低分子肝素組血小板計數(shù)：160.70±45.30；普通肝素組血小板計數(shù)：155.0±36.0，比較無統(tǒng)計學意義，其中二組老年患者血小板比積、平均血小板體積、血小板分布寬度比較P值均大于0.05。 兩組患者中低分子肝素組一共有6例患者出現(xiàn)透析后出血其中4例為輕度出血，2例為明顯，出血人數(shù)占使用低分子肝素人數(shù)6.3%；普通肝素組出現(xiàn)5例輕度出血占使用普通肝素人數(shù)的12.5%。普通肝素組出血率是低分子肝素組的2倍，而且出血的患者抗Xa因子活性均大于1.0IU/ml。 低分子肝素組SF-36生活質(zhì)量評分中生理功能、生理職能、社會功能、情感職能得分為（83.4512.36）（86.788.07）（62.139.34）（86.3713.39）；普通肝素組中SF-36生活質(zhì)量評分中相應項目的得分為（75.4310.36）（81.405.65）（59.467.08）（82.3115.53）；可以看出低分子肝素組得分均高于普通肝素組，但二組比較無統(tǒng)計學意義。軀體疼痛評估得分中低分子肝素組為（61.5811.4），低于普通肝素組得分（72.318.49），P二組比較均P＜0.05，有統(tǒng)計學意義。 3.進一步分析使用低分子肝素抗凝治療的老年患者，以抗Xa因子活性＜ 0.4IU/ml（A組），以0.4IU/ml≤抗Xa因子活性＜1.0IU/ml（B組），抗Xa因子 活性≥1.0IU/ml（C組）；其中A組KT/V值為1.100.08； B組KT/V值為1.450.22， C組KT/V值為1.320.16，B組和C組的KT/V值高于A組（P＜0.05），B組與C組的KT/V值，二組比較無統(tǒng)計學意義。 抗Xa因子活性＜1.0IU/ml的老年患者（A組和B組）均無出血。但在使用低分子肝素組抗Xa因子活性±1.0IU/ml的20例老年患者中有鼻衄、瘀斑或穿刺部位血腫的輕度出血患者4例，出現(xiàn)全身瘀斑伴靜脈穿刺點出血的患者1例。 低分子肝素抗凝治療的老年患者血紅蛋白含量B組（128.4512.82）g/L高于A組(98.576.43)g/L和C組（105.7910.54）g/L（P＜0.05），但A組與C組的血紅蛋白含量，二組比較無統(tǒng)計學意義。血清白蛋白分別為A組（37.032.36）g/L、B組（42.033.17）g/L、C組（36.915.39）g/L，B組高于A和C組（P＜0.05）,A組與C組的血清白蛋白，二組比較無統(tǒng)計學意義。三組中HS-CRP數(shù)值比較無統(tǒng)計學意義，但抗Xa因子活性±1.0IU/ml老年患者HS-CRP高于正常值上限。 使用低分子肝素的長期血液透析的老年患者三組中血漿總膽固醇（TC）、甘油三脂(TG)、高密度脂蛋白(HDL)和低密度脂蛋白(LDL)，兩兩比較均無統(tǒng)計學意義。同時三組中血鈣、血磷及血PTH濃度無統(tǒng)計學差異，其中血磷及PTH均高于正常上限值。 相關(guān)分析顯示抗Xa因子活性與KT/V、ALB、HGB呈正相關(guān)，與PTH呈負相關(guān)。 對于使用低分子肝素長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健康調(diào)查量表各項生活質(zhì)量評分中生理功能、活力、社會功能、精神健康得分高于抗Xa因子活性＜0.4IU/ml（A組），即B組、C組與A組比較，P＜0.05。 結(jié)論 1.長期血液透析老年患者靜脈給予常規(guī)劑量低分子肝素和普通肝素后2小時抗Xa因子活性均為最高，因此檢測老年患者抗Xa因子活性的時間點應在靜脈給藥后2小時。 2.長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.有效劑量的低分子肝素及普通肝素均可以使老年血透患者達到充分透析，兩者治療效果相似。 4.使用低分子肝素抗凝治療的老年血透患者生活質(zhì)量高于使用普通肝素的老年血透患者。 5.將使用低分子肝素抗凝治療的長期血透的老年患者的抗Xa因子活性維持在0.4IU/ml-1.0IU/ml的范圍安全有效。 6.對于經(jīng)濟條件不好的老年患者可以選普通肝素，但低分子肝素對于長期血液透析的老年患者可以改善血脂、炎癥狀態(tài)，其出血副作用小，更值得推薦。
[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.
【學位授予單位】：蘇州大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R692.5

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