| Objective:To investigate the impacts of curative effect, blood cell amounts, bleeding and clotting on which different anticoagulation systems (no heparin or low-dose heparin loop recycling technology) have in molecular adsorbent recirculating system (MARS) in subjects with liver failure. Attempting to establish a safe and individualized anticoagulant model in MARS.Methods:A prospective experimental observation was designed. Patients with liver failure from artificial liver treatment center of Xiangya Hospital, Central South University were randomly divided into two groups according to different anticoagulation meanings. One was no heparin group, in which normal saline was used to irrigate pipes regularly to ensure flow velocity. In case of coagulation, anticoagulants were added immediately, cuing test termination. The other was low-dose heparin group given with half (2050U) or full (4100U) amount of low molecular weight heparin for first dose. And during the whole therapy, anticoagulants were empirically given. Index of liver function (Tbil, DbiL A), renal function (BUN, SCR) and blood cell counts (RBC, Hb, BPC) were compared preoperatively and postoperatively between the two groups. Time points of Omin,30min, 1h,2h,3h,4h 5h and 6h were elected to observe coagulation changes of PT, PTA, TT, APTT and INR dynamically. Adverse events such as line/filter coagulation, rupture and bleeding were also investigated and compared due to frequency and severity between the two groups.Result:1. There were forty-five patients received MARS treatment from August 2009 to August 2010, thirty-two cases of which met the inclusion criteria were recruited. Single treatment lasted for about 6 hours. The whole 18 cases in low-dose heparin group finished the treatment successfully, while there were four cases out of the fourteen cases reached experiment termination, one in which for severe coagulation and the other three cases for clotting.2. Patients in both groups were deep jaundice. Serum protein levels, RBC, Hb, and BPC counts were significant lower than normal before treatment in both groups. Coagulation index such as PT, TT and APTT were significantly prolonged in both groups with PTA≤40%. However, there was no difference between the two groups in basic situation.3. Protein binding toxins and water-soluble toxins such as Tbil, DbiL BUN, SCR were significantly depressed in both groups, and there was no significant difference between them.4. The RBC amount and Hb in low-dose heparin group were 3.210±0.778×10^12/l and 102.523±21.586 g/L before treatment, while 3.018±0.808×10^12/l and 97.076±22.734 g/L after treatment, respectively, indicating no significant differences between the two. Similarly, the RBC amount and Hb in no heparin group were 3.494±0.658×10^12/l and 102.50±35.240 g/L before treatment, while 3.284±0.636×10^12/l, and 107.10±15.445 g/L after treatment, respectively. No significant differences were observed. Further comparison between no heparin group and low-dose heparin group also indicated no significant differences.5. The BPC amount in low-dose heparin group was 107.86±104.54×109/L before MARS while 94.86±108.26×109/L after MARS treatment, no significant difference in decline was obtained (t=1.826, P=0.083). However, in no heparin group it was significantly decreased from 86.70±52.37×109/Lto 60.60±32.78×109/L(t=2.782, P=0.021)6. Eight time points (0min,30min, 1h,2h,3h,4h,5h and 6h in treatment) were selected to observe coagulation changes of PT, PTA, TT, APTT and INR dynamically. There was no difference on PT, PTA, INR between the two groups, but significant differences were observed on APTT and TT and Fbg.APTT:The APTT level in low-dose heparin group was increased rapidly after first given dose of anticoagulant heparin and reached the peak within 30min. While APTT level in no heparin group increased slowly. Further analyse showed that median APTT level at each time point was statistically significant different between the two groups (t 2.201, P= 0.036).TT:The TT level in low-dose heparin group was also increased rapidly, reaching the first peak at the time point of 30min and the second peak at the time point of 4h. In the end of the treatment it was still significantly higher than basic level. However, the TT level in no heparin group maintained a steady state during the whole treatment. And median TT level at each time point was statistically significant different between the two (t= 3.287, P= 0.003).Fbg:A significant difference on Fbg level was obtained between the two groups. In low-dose heparin group it was stabilized and increased slightly at the end of treatment. While in no heparin group it was decreased gradually and reached a ravine at the end of treatment. However, a curve was observed in the treatment of 2.5h between the two groups(F= 3.630, P= 0.001). 7. There were two cases of bleeding, seven cases of clotting in degree I and one case of clotting in degree II in the heparin group; while six cases of clotting in degree I and one case of clotting in degree III in no heparin group. And no case of hypersensitiveness was found in both groups. Thus no signficant difference was observed on complications between the two groups (P=0.845)Conclusion:1. Both low-dose heparin and no heparin systems are likely to cause declining on BPC in MARS treatment of liver failure. However, more obvious was obtained in no heparin group.2. PTA is an important but not the only indicator of blood coagulation in patients with liver failure. Comprehensive analysis of BPC, FDP, D-dimer and clinical symptoms is critical and required to determine the coagulation status to select an anticoagulation system before MARS.3. The use of low dose heparin in MARS improves the disorder of hypercoagulable state during high coaguation period; while no heparin during low coagulation period could effectively prevent the occurrences of bleeding and improve the mechanism of blood coagulation by reducing heparin-like substance in blood. |
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