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中华肾病研究电子杂志 ›› 2013, Vol. 02 ›› Issue (06) : 288 -292. doi: 10.3877/cma.j.issn.2095-3216.2013.06.003

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肾脏病患者血小板减少症的诊治策略
庄永泽1,()   
  1. 1.350025 南京军区福州总医院肾脏病科
  • 出版日期:2013-12-15
  • 通信作者: 庄永泽

Strategies of diagnosis and treatment for thrombocytopenia in patients with renal diseases

Yong-ze ZHUANG1,()   

  1. 1.Department of Nephrology, Fuzhou General Hospital of Nanjing Military Command,Fuzhou 350025, China
  • Published:2013-12-15
  • Corresponding author: Yong-ze ZHUANG
引用本文:

庄永泽. 肾脏病患者血小板减少症的诊治策略[J/OL]. 中华肾病研究电子杂志, 2013, 02(06): 288-292.

Yong-ze ZHUANG. Strategies of diagnosis and treatment for thrombocytopenia in patients with renal diseases[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2013, 02(06): 288-292.

血小板除了止血、促进凝血、维持毛细血管完整性外,还具有调节免疫、募集白细胞、捕获和封存致病原、直接杀死受感染的细胞等功能。 急性肾损伤和慢性肾脏病患者均可出现血小板减少症,但两者在病因及病理生理方面存在差异。 前者病因主要是感染、药物、溶血尿毒综合征(HUS)、血栓性血小板减少性紫癜(TTP)、溶血、肝酶升高、血小板减少(HELLP)综合征,后者病因主要有自身免疫性疾病、肝病、血栓性微血管病(TMA)、特发性血小板减少性紫癜(ITP)、高凝消耗、肝素诱导、药物过敏、尿毒症毒素、血液病及弥散性血管内凝血(DIC)等。 治疗策略包括病因治疗、针对发病机制的治疗、血浆置换、输注血小板、促进血小板形成及对症处理等六个方面。 肾病患者出现血小板减少症时必须关注,它可能是病因诊断的一个重要线索,是反映内皮功能异常、免疫反应介导损伤、血栓栓塞或药物不良反应的一种标志,血小板进行性下降是预后不良的重要信号。

Apart from accelerating hemostasis, promoting clotting, and maintaining the integrity of capillaries, thrombocytes possess functions of regulating the immune system including gathering leukocytes,capturing and containing pathogens, and killing infected cellular targets directly, etc. Thrombocytopenia may occur in both acute kidney injury (AKI)and chronic kidney disease (CKD) patients, but with differences in etiology and pathophysiology. Thrombocytopenia in AKI is mainly caused by infections, medicine, hemolyticuremic syndrome (HUS), thrombotic thrombocytopenie purpura (TTP), and syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). However, thrombocytopenia in CKD is mostly caused by autoimmune diseases, liver diseases, thrombotic microangiopathy (TMA), idiopathic thrombocytopenic purpura (ITP), hyper-coagulation consumption, heparin-induced thrombocytopenia (HIT), drug allergies,uremia toxin, blood diseases, and disseminated intravascular coagulation (DIC), etc. Therapy strategies include etiological treatment, pathogenesis treatment, plasmapheresis, platelet transfusions, promoting platelet formation,and symptomatic treatment. Additional attention should be paid to thrombocytopenia in patients with renal diseases, as it could be an essential clue to the cause of the renal disease, reflecting endothelial dysfunction, immune-mediated damage, thromboembolism, and/or adverse drug reactions. Progressive decrease of platelets may be an important indicator of poor prognosis in patients with renal diseases.

图1 CKD 伴血小板减少症的诊断思路
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