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Safety and efficacy of regional citrate anticoagulation for continuous renal replacement therapy in liver failure patients: a systematic review and meta-analysis

Wei Zhang, Ming Bai1, Yan Yu, Lu Li, Lijuan Zhao, Shiren Sun and Xiangmei Chen

Critical care (London, England), 2019, 23(1): 22.

Background

Regional citrate anticoagulation (RCA) is a widely used strategy for continuous renal replacement therapy (CRRT). Most of the current guidelines recommend liver failure as one of the contraindications for citrate anticoagulation. However, some studies suggested that the use of citrate for CRRT in liver failure patients did not increase the risk of citrate-related complications. The purpose of this systematic review is to summarize the current evidences on the safety and efficacy of RCA for CRRT in liver failure patients.

背景

局部枸櫞酸抗凝（RCA）廣泛應(yīng)用于持續(xù)腎臟替代治療（CRRT）。目前大多數(shù)指南的推薦將肝衰竭作為枸櫞酸抗凝禁忌癥之一。然而，有研究表明，肝衰竭患者在CRRT時(shí)使用枸櫞酸并未增加枸櫞酸相關(guān)并發(fā)癥的風(fēng)險(xiǎn)。本系統(tǒng)回顧目的是總結(jié)目前CRRT時(shí)RCA對(duì)于肝衰竭患者的安全性和有效性的證據(jù)。

Methods

We performed a comprehensive search on PubMed, Embase, and the Cochrane Library databases from the inception to March 1, 2018. Studies enrolled adult (age > 18 years) patients with various levels of liver dysfunction underwent RCA-CRRT were included in this systematic review.

方法

我們綜合搜索PubMed，Embase和Cochrane Library數(shù)據(jù)庫(kù)從最初到2018年3月1日的數(shù)據(jù)。本系統(tǒng)回顧納入了接受RCA-CRRT的不同程度肝功能異常的成年（年齡>18歲）患者。

Results

After the study screening, 10 observational studies with 1241 liver dysfunction patients were included in this systematic review. The pooled rate of citrate accumulation and bleeding was 12% [3%, 22%] and 5% [2%, 8%], respectively. Compared with the baseline data, the serum pH, bicarbonate, and base excess (BE), the rate of metabolic alkalosis, the serum ionized calcium (ionCa) and total calcium (totCa) level, and the ratio of total calcium/ionized calcium (totCa/ionCa) significantly increased at the end of observation.However, no significant increase was observed in serum citrate (MD ? 65.82 [? 194.19, 62.55]), lactate (MD 0.49 [? 0.27, 1.26]) and total bilirubin concentration (MD 0.79 [? 0.70, 2.29]) at the end of CRRT. Compared with non-liver failure patients, the liver failure patients showed no significant difference in the pH (MD ? 0.04 [? 0.13, 0.05]), serum lactate level (MD 0.69 [? 0.26, 1.64]), and totCa/ionCa ratio (MD 0.03 [? 0.12, 0.18]) during CRRT. The median of mean filter lifespan was 55.9 h, with a range from 22.7 to 72 h.

結(jié)果

研究篩選后，本系統(tǒng)回顧共納入10個(gè)觀察性研究1241肝功能異常患者。枸櫞酸蓄積和出血發(fā)生率分別為12%（3%，22%）和5%（2%，8%）。與基線數(shù)據(jù)相比，觀察結(jié)束時(shí)血清pH值，碳酸氫鹽，堿剩余，代謝性堿中毒發(fā)生率，血清離子鈣和總鈣水平，以及總鈣與離子鈣的比值均顯著增加。然而，在CRRT結(jié)束后，沒(méi)有觀察到血清中檸檬酸（MD ?65.82 [?194.19，62.55]），乳酸（MD 0.49 [?0.27，1.26]）和總膽紅素濃度（MD 0.79 [?0.70，2.29]）有顯著增加。與非肝衰竭患者相比，肝衰竭患者CRRT治療過(guò)程中，pH值（MD ?0.04 [?0.13，0.05]），血清乳酸水平（MD 0.69 [?0.26，1.64]）和總鈣/離子鈣比率（MD 0.03 [?0.12，0.18]）均沒(méi)有明顯差異。

Conclusions

Regional citrate anticoagulation seems to be a safe anticoagulation method in liver failure patients underwent CRRT and could yield a favorable filter lifespan. Closely monitoring the acid base status and electrolyte balance may be more necessary during RCA-CRRT in patients with liver failure.

結(jié)論

RCA在肝衰竭患者進(jìn)行CRRT治療時(shí)似乎是一個(gè)安全的抗凝方法，而且能產(chǎn)生良好的濾器壽命。在肝衰竭患者進(jìn)行RCA-CRRT時(shí)，密切監(jiān)測(cè)酸堿狀態(tài)和電解質(zhì)平衡可能更有必要。

北京市昌平區(qū)醫(yī)院  沙偉偉譯