Objective: To investigate anticoagulation effects of nafamostat mesylate(NM) in sustained low-efficiency dialysis (SLED) and its relevant factors. Methods: Critically ill patients with kidney disease who were admitted to Zhongshan Hospital Affiliated to Fudan University and underwent SLED treatment from May to August 2024 were retrospectively included. Baseline clinical data were collected, and the activated partial thromboplastin time (APTT) and activated clotting time (ACT) were measured at the arterial end, before the filter, and at the venous end two hours post-NM anticoagulation treatment. Patients were categorized into two groups: the anticoagulation achievement group and the anticoagulation non-achievement group, based on the observed clotting status of the filter and venous reservoir following treatment completion. Multivariate logistic regression analysis was employed to identify risk factors influencing the efficacy of NM anticoagulation. Additionally, the receiver operating characteristic (ROC) curve was utilized to ascertain optimal monitoring indicators for NM anticoagulation. Results: A total of 96 patients (64 males and 32 females) aged (60±18) years undergoing SLED were included in the study, with 75 patients in the anticoagulation achievement group and 21 patients in the anticoagulation non-achievement group. No statistically significant differences were observed in baseline characteristics such as age, gender, body weight, baseline liver and kidney function, and platelet count between the two groups (all P>0.05). The proportion of patients with a baseline hematocrit (HCT)>30% was higher in the anticoagulation non-achievement group than that in the achievement group [57.1% (12/21) vs 22.7% (17/75), P=0.009]. The proportion of patients with fibrinogen (Fib)>4 g/L was also higher in the anticoagulation non-achievement group [90.5% (19/21) vs 49.3% (37/75), P<0.001]. The ultrafiltration rate in the anticoagulation achievement group was lower than that in the non-achievement group [232 (182, 353) ml/h vs 478 (289, 691) ml/h, P<0.001], and the NM dose was higher in the achievement group [35 (30, 40) mg/h vs 30 (25, 35) mg/h, P<0.001]. Multivariate logistic regression analysis revealed that high ultrafiltration rate (OR=1.489, 95%CI: 1.007-2.145, P<0.001), HCT>30% (OR=6.907, 95%CI: 1.523-18.342, P=0.009), and low albumin level (OR=0.821, 95%CI: 0.709-0.951, P=0.002) were relevant factors for poor NM efficacy. After 2 hours of NM treatment, the ratio of ACT at the venous/baseline ACT and the ratio of APTT at the venous/baseline APTT in the anticoagulation achievement group were both higher than those in the non-achievement group (both P<0.05). There was a positive correlation between APTT and ACT measured at the venous end 2 hours after NM treatment (r=0.763, P<0.001). The ROC curve analysis results showed that the area under the curve (AUC) for determining the effectiveness of NM anticoagulation using the ratio of APTT at the venous end to baseline APTT at 2 hours was 0.845 (95%CI: 0.762-0.928, P<0.001), with a cut-off value of 1.78 (sensitivity: 89.8%; specificity: 68.6%). Conclusions: Higher filtration rate, HCT>30% and lower albumin levels are identified as relevant factors for poor NM efficacy. Additionally, the ratio of venous/baseline APTT at 2 h after NM treatment may serve as a predictive indicator for assessing of NM anticoagulation.
目的： 探讨甲磺酸萘莫司他（NM）在床旁长时缓慢血液透析（SLED）治疗中的抗凝效果及其相关因素。 方法： 回顾性纳入2024年5至8月在复旦大学附属中山医院住院并行SLED治疗的危重肾脏病患者，收集基线临床资料，检测NM抗凝治疗2 h动脉端、滤器前和静脉端活化部分凝血活酶时间（APTT）和活化凝血时间（ACT），根据治疗结束后滤器和静脉壶凝血情况，分为抗凝达标组和抗凝不达标组。采用logistic回归分析影响NM抗凝效果的危险因素，受试者工作特征（ROC）曲线分析抗凝监测指标评估NM抗凝效果的价值。 结果： 共纳入96例患者，男64例，女32例，年龄（60±18）岁。抗凝达标组75例，抗凝不达标组21例。两组年龄、性别、体重、基础肝肾功能、血小板差异均无统计学意义（均P>0.05）。抗凝不达标组基线血细胞比容（HCT）>30%的比例［57.1%（12/21）比22.7%（17/75），P=0.009］、纤维蛋白原（Fib）>4 g/L的比例［90.5%（19/21）比49.3%（37/75），P<0.001］、超滤率［478（289，691）ml/h比232（182，353）ml/h，P<0.001］均高于达标组，NM剂量［30（25，35）mg/h比35（30，40）mg/h，P<0.001］低于达标组。多因素logistic回归分析结果显示，高超滤率（OR=1.489，95%CI：1.007~2.145，P<0.001）、HCT>30%（OR=6.907，95%CI：1.523~18.342，P=0.009）和低白蛋白水平（OR=0.821，95%CI：0.709~0.951，P=0.002）是NM抗凝效果不佳的相关因素。NM治疗2 h抗凝达标组静脉端ACT/基线ACT比值和2 h静脉端APTT/基线APTT比值均高于不达标组（均P<0.05）；NM治疗2 h静脉端检测的APTT和ACT呈正相关（r=0.763，P<0.001）。ROC曲线分析结果显示，2 h静脉端APTT/基线APTT比值判断NM抗凝效果的曲线下面积（AUC）为0.845（95%CI：0.762~0.928，P<0.001），cut-off值为1.78，灵敏度89.8%，特异度68.6%。 结论： 高超滤率、HCT>30%和低白蛋白水平是NM抗凝效果不佳的相关因素，NM治疗2 h静脉端APTT/基线APTT比值有助于评估NM抗凝效果。.