Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials
Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials
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DOI：
10.1053/j.ajkd.2011.11.030
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发表时间：
2012-06-01
影响因子：
13.2
通讯作者：
Tam, Ka-Wai
中科院分区：
文献类型：
--
作者：
Wu, Mei-Yi;Hsu, Yung-Ho;Tam, Ka-Wai
背景：连续性肾脏替代治疗（CRRT）需要体外回路抗凝。肝素是抗凝的经典选择，尽管它可能会增加出血的风险。局部柠檬酸盐抗凝可降低出血风险，但可能导致低钙血症和代谢紊乱。研究设计：随机对照试验（RCT）的系统综述和荟萃分析。设置和人群：因急性肾损伤而入住重症监护室并需要CRRT的患者。研究选择标准：RCT，不考虑出版状态或语言。干预：CRRT中局部柠檬酸盐抗凝与肝素抗凝的比较。结局：主要结局为回路存活时间、大出血发生率（定义为大出血部位伴血压降低或需要输注2个或更多单位红细胞）、代谢性水肿、低钙血症，和血小板减少症。结果：共纳入6项随机对照试验，488例患者。柠檬酸盐抗凝治疗与出血显著减少相关（RR，0.34; 95% CI，0.17-0.65）。循环存活时间、代谢性血小板减少症和血小板减少症的发生率在组间无显著差异。低钙血症在接受柠檬酸盐的患者中更常见，尽管在纳入的研究中没有报告临床不良事件。局限性：主要结局的显著异质性。结论：柠檬酸盐和肝素抗凝治疗CRRT的疗效相似。然而，柠檬酸盐抗凝治疗可降低出血风险，且代谢性水肿的发生率未显著增加。我们建议柠檬酸盐作为需要CRRT但出血风险高的患者的抗凝剂。美国肾脏病杂志59（6）：810-818。(C)2012年，美国国家肾脏基金会（National Kidney Foundation，Inc.）
Background: Anticoagulation of the extracorporeal circuit is required in continuous renal replacement therapy (CRRT). Heparin is the classic choice for anticoagulation, although it may increase the risk of bleeding. Regional citrate anticoagulation reduces the risk of bleeding, but may cause hypocalcemia and metabolic disturbances.Study Design: Systematic review and meta-analysis of randomized controlled trials (RCTs).Setting & Population: Patients admitted to the intensive care unit with acute kidney injury that required CRRT.Selection Criteria for Studies: RCTs regardless of publication status or language.Intervention: Regional citrate versus heparin anticoagulation in CRRT.Outcomes: The primary outcomes were circuit survival time, the occurrence of major bleeding defined as a site of gross bleeding with a decrease in blood pressure or requiring transfusion of 2 or more units of red blood cells, metabolic alkalosis, hypocalcemia, and thrombocytopenia. The secondary outcome was cost.Results: 6 RCTs with 488 patients were identified. Citrate anticoagulation was associated with a significant decrease in bleeding (RR, 0.34; 95% CI, 0.17-0.65). Circuit survival time, the incidence of metabolic alkalosis, and thrombocytopenia showed no significant difference between groups. Hypocalcemia was more common in patients receiving citrate, although no clinical adverse event was reported in the included studies.Limitations: Significant heterogeneity in the primary outcome.Conclusion: The efficacy of citrate and heparin anticoagulation for CRRT was similar. However, citrate anticoagulation decreased the risk of bleeding with no significant increase in the incidence of metabolic alkalosis. We recommend citrate as an anticoagulation agent in patients who require CRRT but are at high risk of bleeding. Am J Kidney Dis. 59(6):810-818. (C) 2012 by the National Kidney Foundation, Inc.