连续性肾脏替代治疗体外循环装置凝血风险预测模型的构建与验证

doi:10.3761/j.issn.0254-1769.2023.15.009

摘要/Abstract

摘要：

目的建立预测连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）体外循环装置凝血风险的模型，并验证模型的应用效果。方法采用便利抽样法，收集2021年4月—2022年1月在常州市某三级甲等医院行CRRT的患者320例，按照是否发生体外循环装置凝血分为凝血组（n=98）和非凝血组（n=222），将两组的各项指标进行对比并应用二元Logistic回归构建预测模型，采用Hosmer-Lemeshow判断模型的拟合度，采用受试者操作特征曲线（receiver operating characteristic curve，ROC）的曲线下面积检验模型预测效果。将2022年2月—6月行CRRT的160例患者作为验证组，验证模型的临床应用效果。结果体外循环装置凝血发生率为30.6%，最终纳入模型的预测变量为连续性静脉-静脉血液透析（continuous venovenous hemodialysis，CVVHD）（OR=2.482）、连续性静脉-静脉血液滤过（continuous venovenous hemofiltration，CVVH）（OR=2.724）、枸橼酸抗凝（OR=3.425）、阿加曲班抗凝（OR=3.150）、无肝素抗凝（OR=9.103）、血泵停泵（OR=4.114）、血流量不足（OR=2.769）、血小板计数（OR=1.005）和活化部分凝血活酶时间（OR=0.859）。风险预测模型公式为P=1/[1+exp（-0.866+0.909 × CVVHD+1.002 × CVVH+1.231 × 枸橼酸抗凝+1.147 × 阿加曲班抗凝+2.209 × 无肝素抗凝+1.415 × 血泵停泵+1.018 × 血流量不足+0.005 × 血小板计数-0.152 × 活化部分凝血活酶时间）]。该模型ROC曲线下面积为0.865，最大约登指数为0.584，灵敏度为75.50%，特异度为82.90%。模型验证结果：灵敏度为84.10%，特异度为79.31%，准确率为80.63%。结论该研究构建的模型预测效果较好，可为临床识别CRRT患者凝血的发生及实施预防性护理提供借鉴。

关键词: 连续性肾脏替代治疗, 凝血, 风险预测模型, 护理

Abstract:

Objective To construct and verify a predictive model to assess the risk of extracorporeal circuit clotting during continuous renal replacement therapy（CRRT）. Methods A total of 320 patients with CRRT were enrolled from April 2021 to January 2022，and risk factors between a blockage group（222 cases） and a non-blockage group（98 cases） were compared using logistic regression for model construction. The goodness of fit of the model was verified by Hosmer-Lemeshow test. The predictive validity of the model was evaluated by the area under the ROC curve. From February to June 2022，160 patients were recruited for application of the model. Results The incidence of coagulation in this study was 30.6%. The factors that ultimately entered the predictive model were CVVHD mode of treatment（OR=2.482），CVVH mode of treatment（OR=2.724），citrate anticoagulation（OR=3.425），argatroban（OR=3.150），without anticoagulation（OR=9.103），pump interruption（OR=4.114），access outflow dysfunction（OR=2.769），the platelet count（OR=1.005），and APTT（OR=0.859）. The model formula was P=1/[1+exp（-0.866+0.909 × CVVHD+1.002 × CVVH+1.231×citrate anticoagulation+1.147 × argatroban+2.209 × without anticoagulation+1.415 × pump interruption+1.018 × access outflow dysfunction+0.005 × the platelet count-0.152 × APTT）]. The area under the ROC curve was 0.865，while the Youden index was 0.584，with sensitivity of 75.50% and specificity of 82.90%. The model verification results showed the sensitivity of 84.10%，the specificity of 79.31%，and the accuracy of 80.63%. Conclusion The risk prediction model has satisfactory prediction effects. The risk prediction can be completed at the beginning of CRRT，which can provide references for preventative treatment and nursing measures for high-risk patients.

Key words: Continuous Renal Replacement Therapy, Clotting, Risk Prediction Model, Nursing Care

胡璐璐, 牛洪艳, 韩小云, 祝喜鹰, 刘金凤. 连续性肾脏替代治疗体外循环装置凝血风险预测模型的构建与验证[J]. 中华护理杂志, 2023, 58(15): 1845-1851.

HU Lulu, NIU Hongyan, HAN Xiaoyun, ZHU Xiying, LIU Jinfeng. The development and application of a risk prediction model for extracorporeal circuit clotting during continuous renal replacement therapy[J]. Chinese Journal of Nursing, 2023, 58(15): 1845-1851.

图/表 4

表1 体外循环装置发生凝血的单因素分析结果

Table 1 Single factor analysis results of extracorporeal circuit clotting

表2 二元Logistics回归自变量赋值方式

Table 2 The assignment of the independent variable

表3 体外循环装置凝血的Logistic回归分析结果

Table 3 Logistic regression analysis results of extracorporeal circuit clotting

图1 预测体外循环装置凝血的受试者操作特征曲线

Figure 1 ROC curve of risk factor prediction model for extracorporeal circuit clotting

参考文献 33

[1]	Ricci Z, Romagnoli S, Ronco C, et al. From continuous renal replacement therapies to multiple organ support therapy[J]. Contrib Nephrol, 2018, 194:155-169. DOI PMID
[2]	张勇. 持续性肾脏替代治疗的临床过程安全管理研究[D]. 沈阳: 中国医科大学, 2020.
	Zhang Y. Safety management of clinical process of continuous renal replacement therapy[D]. Shenyang: China Medical University, 2020.
[3]	Tanaka M, Moniwa N, Ohnishi H, et al. Impact of the number of anti-thrombosis agents in hemodialysis patients:BOREAS-HD2 study[J]. Kidney Blood Press Res, 2017, 42(3):553-564. DOI URL
[4]	Skagerlind MSE, Stegmayr BG. An evaluation of four modes of low-dose anticoagulation during intermittent haemodialysis[J]. Eur J Clin Pharmacol, 2018, 74(3):267-274. DOI PMID
[5]	黄琪, 孙雪峰. 维持性血液透析的抗凝剂:选择普通肝素还是低分子肝素[J]. 中国血液净化, 2015, 14(1):60-62.
	Huang Q, Sun XF. Anticoagulants for maintenance hemodialysis:ordinary heparin or low molecular weight heparin?[J]. Chin J Blood Purif, 2015, 14(1):60-62.
[6]	吴春燕, 叶志弘, 柴剑丽, 等. 并联式双静脉壶透析管路的设计及应用效果研究[J]. 中华护理杂志, 2017, 52(4):496-499.
	Wu CY, Ye ZH, Chai JL, et al. The design and effects of parallel double venous pots hemodialysis tubing set[J]. Chin J Nurs, 2017, 52(4):496-499.
[7]	邱德俊, 李新伦, 高卓, 等. 简化法局部枸橼酸与阿加曲班抗凝在高危出血风险血液透析患者中的对比观察[J]. 临床肾脏病杂志, 2020, 20(6):449-453.
	Qiu DJ, Li XL, Gao Z, et al. Comparative observation of anticoagulant effect of simplified-regional citrate and argatroban in patients with hemodialysis at high risk of bleeding[J]. J Clin Nephrol, 2020, 20(6):449-453.
[8]	中国重症血液净化协作组, 中国重症血液净化协作组护理学组, 赵琳, 等. 中国重症血液净化护理专家共识(2021年)[J]. 中华现代护理杂志, 2021, 27(34):4621-4632.
	China Critical Care Blood Purification Cooperation Group, Nursing Group of China Critical Care Blood Purification Cooperation Group, Zhao L, et al. Expert consensus on the nursing of critical blood purification in China(2021)[J]. Chin J Mod Nurs, 2021, 27(34):4621-4632.
[9]	向泳燕. 连续性血液净化患者体外循环凝血风险评估量表的研制[D]. 太原: 山西医科大学, 2022.
	Xiang YY. Development of extracorporeal circulation coagulation risk assessment scale for continuous blood purification patients[D]. Taiyuan: Shanxi Medical University, 2022.
[10]	宋利, 符霞, 全梓林, 等. 持续性肾脏替代治疗体外循环堵塞相关因素分析[J]. 护理研究, 2015, 29(13):1608-1612.
	Song L, Fu X, Quan ZL, et al. Analysis on related factors of cardiopulmonary bypass clogged in patients undergoing continuous renal replacement therapy[J]. Chin Nurs Res, 2015, 29(13):1608-1612.
[11]	Brain M, Winson E, Roodenburg O, et al. Non anti-coagulant factors associated with filter life in continuous renal replacement therapy(CRRT):a systematic review and meta-analysis[J]. BMC Nephrol, 2017, 18(1):69. DOI URL
[12]	张仲华, 曾铁英, 黄博伦, 等. 无抗凝连续性肾脏替代治疗体外循环装置使用时间影响因素的研究[J]. 护理学杂志, 2019, 34(13):22-27.
	Zhang ZH, Zeng TY, Huang BL, et al. Study on factors influencing lifespan of the extracorporeal circuit device in continuous renal replacement therapy without anticoagulation[J]. J Nurs Sci, 2019, 34(13):22-27.
[13]	Fu X, Liang XL, Song L, et al. Building and validation of a prognostic model for predicting extracorporeal circuit clotting in patients with continuous renal replacement therapy[J]. Int Urol Nephrol, 2014, 46(4):801-807. DOI PMID
[14]	王海波, 李克鹏, 徐丽娟, 等. 重症合并急性肾损伤患者持续静脉-静脉血液透析滤过治疗时滤器凝血预测模型的建立与评价[J]. 潍坊医学院学报, 2019, 41(1):52-54,74.
	Wang HB, Li KP, Xu LJ, et al. Establishment of regression model of clotting of dialysers during continuous haemodiafiltration in critically ill patients with acute kidney injury for prediction and evaluation of efficacy[J]. Acta Acad Med Wei-fang, 2019, 41(1):52-54,74.
[15]	王质刚. 血液净化学[M]. 4版. 北京: 北京科学技术出版社, 2016:535-536.
	Wang ZG. Blood purification[M]. 4th ed. Beijing: Beijing Science &Technology Press, 2016:535-536.
[16]	Zhang L, Tanaka A, Zhu GJ, et al. Patterns and mechanisms of artificial kidney failure during continuous renal replacement therapy[J]. Blood Purif, 2016, 41(4):254-263. DOI URL
[17]	刘翔, 龚德华, 季大玺, 等. 连续性肾脏替代治疗患者体外循环凝血的危险因素及护理研究进展[J]. 中华护理杂志, 2013, 48(4):377-379.
	Liu X, Gong DH, Ji DX, et al. Influencing factors of circuit patency for continuous renal replacement therapies and contermeasures:a review[J]. Chin J Nurs, 2013, 48(4):377-379.
[18]	何长民, 张训. 肾脏替代治疗学[M]. 2版. 上海: 上海科技教育出版社, 2005:66-67.
	He CM, Zhang X. Renal replacement therapy[M]. 2nd ed. Shanghai: Shanghai Scientific & Technological Education Publishing House, 2005:66-67.
[19]	Daugirdas JT, Blake PG, Ing TS. Handbook of Dialysis[M]. 4th ed. Philadelphia,PA: Lippincott Wilkins, USA, 2008:215-217.
[20]	Oudemans-van Straaten HM, Wester JPJ, de Pont ACJM, et al. Anticoagulation strategies in continuous renal replacement therapy:can the choice be evidence based?[J]. Intensive Care Med, 2006, 32(2):188-202. DOI URL
[21]	唐小琰, 陈德政, 张凌, 等. 局部枸橼酸抗凝在血液净化领域中的应用进展[J]. 中华肾脏病杂志, 2021, 37(6):534-538. DOI
	Tang XY, Chen DZ, Zhang L, et al. Application progress of regional citrate anticoagulation in the field of blood purification[J]. Chin J Nephrol, 2021, 37(6):534-538. DOI
[22]	周才芳, 姚筱. 高出血风险的血液透析患者抗凝方案优化[J]. 中华保健医学杂志, 2021, 23(5):438-440.
	Zhou CF, Yao X. Optimization of anticoagulation regimen for hemodialysis patients with high risk of bleeding[J]. Chin J Health Care Med, 2021, 23(5):438-440.
[23]	袁娟. 低分子肝素钠与枸橼酸钠对血液透析在高危出血风险患者中的临床对比观察[J]. 中国输血杂志, 2022, 35(1):39-42.
	Yuan J. Effects of low molecular weight heparin sodium and sodium citrate on hemodialysis patients at high risk of bleeding:a comparative study[J]. Chin J Blood Transfus, 2022, 35(1):39-42.
[24]	卢亮, 周娜, 徐玉, 等. 改良枸橼酸钠输注法在连续性血液净化患者中的应用[J]. 中华护理杂志, 2020, 55(12):1850-1854. DOI URL
	Lu L, Zhou N, Xu Y, et al. Application of modified citrate infusion method for patients under continuous renal replacement therapy[J]. Chin J Nurs, 2020, 55(12):1850-1854. DOI URL
[25]	杨建国, 何细飞, 鄢建军, 等. 无肝素连续性肾脏替代治疗体外循环凝血预防及管理的最佳证据总结[J]. 护理学报, 2022, 29(10):54-59.
	Yang JG, He XF, Yan JJ, et al. Best evidence summary of prevention and management of coagulation during continuous renal replacement therapy without heparin[J]. J Nurs China, 2022, 29(10):54-59.
[26]	Baldwin I, Bellomo R, Koch B. Blood flow reductions during continuous renal replacement therapy and circuit life[J]. Intensive Care Med, 2004, 30(11):2074-2079. DOI URL
[27]	张珂, 黄丽璇, 吕桂兰. 连续性血液净化体外循环静脉壶凝血的危险因素分析及预防措施进展[J]. 医学研究生学报, 2018, 31(3):328-332.
	Zhang K, Huang LX, Lü GL. Risks and precaution of bubble chamber clotting in continuous blood purification[J]. J Med Postgrad, 2018, 31(3):328-332.
[28]	莫雅文, 宋利, 韩晓苇, 等. 血液透析治疗中泵前动脉压与泵控血流量比值的临床研究[J]. 中国血液净化, 2019, 18(8):579-581,584.
	Mo YW, Song L, Han XW, et al. A survey on the ratio of pre-pump arterial pressure and blood flow rate during hemodialysis treatment[J]. Chin J Blood Purif, 2019, 18(8):579-581,584.
[29]	芦静, 王薇. 血液透析血路管静脉壶堵塞的原因及其护理进展[J]. 护理研究, 2016, 30(31):3851-3854.
	Lu J, Wang W. Cause of clogging of vena cava of blood pipeline in hemodialysis and its nursing progress[J]. Chin Nurs Res, 2016, 30(31):3851-3854.
[30]	黄美春, 庄耀宁, 陈敏敏, 等. 无肝素连续性肾脏替代治疗血液透析导管堵塞临床征象及相关因素分析[J]. 全科护理, 2021, 19(22):3089-3094.
	Huang MC, Zhuang YN, Chen MM, et al. Clinical signs and related factors of heparin-free continuous renal replacement therapy for hemodialysis catheter obstruction[J]. Chin Gen Pract Nurs, 2021, 19(22):3089-3094.
[31]	Smith SA, Travers RJ, Morrissey JH. How it all starts:initiation of the clotting cascade[J]. Crit Rev Biochem Mol Biol, 2015, 50(4):326-336. DOI URL
[32]	Arcangeli A, Rocca B, Salvatori G, et al. Heparin versus prostacyclin in continuous hemodiafiltration for acute renal failure:effects on platelet function in the systemic circulation and across the filter[J]. Thromb Res, 2010, 126(1):24-31. DOI PMID
[33]	施姣姣, 颜清, 杨沭, 等. 华法林、达比加群酯和低分子肝素对心房颤动射频导管消融术中活化凝血时间达标情况及潜在血栓形成风险的影响[J]. 中国循环杂志, 2022, 37(5):465-471.
	Shi JJ, Yan Q, Yang S, et al. The influence of warfarin,dabigatran and low molecular weight heparin on achieving standard activated clotting time and potential risk for embolism during catheter ablation of atrial fibrillation[J]. Chin Circ J, 2022, 37(5):465-471.