血透患者的抗凝治疗
Anticoagulation Therapy for Hemodialysis Patients

安全、有效的抗凝是保证血液透析能够顺利进行的前提。肝素抗凝是目前临床上最常使用的血透抗凝方案，此外阿加曲班、枸橼酸钠、甲磺酸萘莫司他、无肝素生理盐水冲洗等在血液透析中的运用也越来越广泛。血液透析通过弥散、对流等方式从而发挥清除毒素、去除多余水分、维持电解质及酸碱平衡、提供临时肾脏的替代治疗的作用，在临床中运用越来越广泛。在血液透析过程中，充分的抗凝对于维持血液在体外循环的流动状态，避免体外凝血导致血液丢失、诱发血栓栓塞性疾病，保证血液透析患者“生命线”畅通无阻至关重要。在临床实践中，血液透析的抗凝治疗应在充分评估患者凝血状态基础上，明确不同抗凝剂的适应症及禁忌症，选择合适的抗凝剂及剂量，并在抗凝治疗前、中、后分别监测、评估血透患者凝血指标，及时调整抗凝剂剂量，防止不良反应的发生，并积极处理并发症，保障血液透析顺利进行。抗凝剂种类繁多，目前临床常用的有普通肝素、低分子肝素、阿加曲班、枸橼酸钠、甲磺酸萘莫司他等，由于肾功能衰竭患者多有血小板黏附和聚集功能障碍，出血发生率高，对于高危出血风险患者甚至使用无肝素生理盐水冲洗等抗凝方案，但优缺点各异，现将血透患者常用的抗凝方案做一综述。
Safe and effective anticoagulation is a prerequisite for ensuring the smooth progress of hemodialysis. Heparin anticoagulation is currently the most commonly used anticoagulation regimen for hemodialysis in clinical practice. In addition, the use of argatroban, sodium citrate, naprolimus mesylate, and heparin free saline flushing in hemodialysis is becoming increasingly widespread. Hemodialysis plays a role in clearing toxins, removing excess water, maintaining electrolyte and acid-base balance, and providing temporary kidney replacement therapy through diffusion, convection, and other methods, and is becoming increasingly widely used in clinical practice. Adequate anticoagulation is crucial in maintaining the flow of blood in the extracorporeal circulation during hemodialysis, avoiding blood loss caused by extracorporeal coagulation and inducing thromboembolic diseases, and ensuring that the “lifeline” of hemodialysis patients is unobstructed. In clinical practice, anticoagulant therapy for hemodialysis should be based on a thorough evaluation of the patient’s coagulation status, clarifying the indications and contraindications of different anticoagulants, selecting appropriate anticoagulants and dosages, and monitoring and evaluating the coagulation indicators of hemodialysis patients before, during, and after anticoagulant therapy. The dosage of anticoagulants should be adjusted in a timely manner to prevent adverse reactions and actively deal with complications to ensure the smooth progress of hemodialysis. There are many types of anticoagulants, and currently commonly used in clinical practice include unfractionated heparin, low-molecular-weight heparin, argatroban, sodium citrate, and naprolimus mesylate. Due to platelet adhesion and aggregation dysfunction in patients with renal failure, the incidence of bleeding is high. For high-risk bleeding patients, anticoagulation regimens such as heparin