Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis.
Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis.
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DOI：
10.1186/s12882-017-0445-5
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发表时间：
2017-02-20
期刊：
影响因子：
2.3
通讯作者：
McNeil J
中科院分区：
文献类型：
--
作者：
Brain M;Winson E;Roodenburg O;McNeil J
优化连续肾脏替代治疗中的过滤器寿命和性能效率一直是近期研究的重点。更大规模的高质量研究主要集中在最佳抗凝治疗上，但 CRRT 很复杂，过滤器寿命也受到血管通路、回路和管理因素的影响。我们对文献进行了系统检索，以确定和量化影响过滤器寿命的血管通路、回路和患者因素的影响，并将结果作为荟萃分析呈现。通过搜索 Pubmed (MEDLINE) 和 Ovid EMBASE 库，从开始到 2016 年 2 月 29 日，对所有使用与 CRRT 回路相关的比较器或自变量并报告过滤器寿命的研究进行了系统回顾和荟萃分析。纳入的研究记录了除抗凝干预之外的比较器的过滤器寿命（以小时为单位）。所有比较抗凝干预措施的研究均搜索了与过滤器寿命变化的其他来源相关的回归或危险模型。确定了 819 份摘要，其中 364 份被选择进行全文分析。 24 项提供了关于患者回路寿命调节因素的数据，14 项提供了关于血管通路调节剂的数据，34 项提供了关于回路相关因素的数据。偏倚风险很高，研究结果正在产生假设。按过滤器寿命对血管通路部位进行排序：隧道式半永久性导管、股动脉、颈内静脉和锁骨下静脉最后。股动脉导管和颈静脉导管之间报告的差异不一致。在已发表的文献中，CRRT 的方式始终倾向于连续静脉-静脉血液透析滤过 (CVVHD-F)，与 CVVH 相比，其失败率降低 44%。有一种趋势有利于更高的血流速度。没有足够的数据来确定滤血膜的优点。与过滤器寿命显着恶化相关的患者因素包括机械通气、SOFA 或 LOD 评分升高、离子钙升高、血小板计数升高、红细胞输注、血小板因子 4 (PF-4) 抗体和纤维蛋白原升高。大多数研究都是在子分析中观察或报告回路因素。偏见风险很高，调查结果需要有针对性的调查来确认。患者、病理、抗凝、血管通路、回路和工作人员因素的相互作用影响 CRRT 过滤器的寿命。从已发表的数据来看，对于血管通路放置的首选部位和一侧以及这与患者因素和时间有何相互作用，仍然存在模糊性。如果预计 CRRT 时间较长，尽早考虑隧道式半永久性通道可能会提供最佳的过滤器寿命。尽管已有 20 多年的治疗经验，但除了抗凝策略外，仍然缺乏强有力的证据，但趋势显示 CVVHD-F 优于 CVVH。
Optimising filter life and performance efficiency in continuous renal replacement therapy has been a focus of considerable recent research. Larger high quality studies have predominantly focussed on optimal anticoagulation however CRRT is complex and filter life is also affected by vascular access, circuit and management factors. We performed a systematic search of the literature to identify and quantify the effect of vascular access, circuit and patient factors that affect filter life and presented the results as a meta-analysis. A systematic review and meta-analysis was performed by searching Pubmed (MEDLINE) and Ovid EMBASE libraries from inception to 29th February 2016 for all studies with a comparator or independent variable relating to CRRT circuits and reporting filter life. Included studies documented filter life in hours with a comparator other than anti-coagulation intervention. All studies comparing anticoagulation interventions were searched for regression or hazard models pertaining to other sources of variation in filter life. Eight hundred nineteen abstracts were identified of which 364 were selected for full text analysis. 24 presented data on patient modifiers of circuit life, 14 on vascular access modifiers and 34 on circuit related factors. Risk of bias was high and findings are hypothesis generating. Ranking of vascular access site by filter longevity favours: tunnelled semi-permanent catheters, femoral, internal jugular and subclavian last. There is inconsistency in the difference reported between femoral and jugular catheters. Amongst published literature, modality of CRRT consistently favoured continuous veno-venous haemodiafiltration (CVVHD-F) with an associated 44% lower failure rate compared to CVVH. There was a trend favouring higher blood flow rates. There is insufficient data to determine advantages of haemofilter membranes. Patient factors associated with a statistically significant worsening of filter life included mechanical ventilation, elevated SOFA or LOD score, elevations in ionized calcium, elevated platelet count, red cell transfusion, platelet factor 4 (PF-4) antibodies, and elevated fibrinogen. Majority of studies are observational or report circuit factors in sub-analysis. Risk of bias is high and findings require targeted investigations to confirm. The interaction of patient, pathology, anticoagulation, vascular access, circuit and staff factors contribute to CRRT filter life. There remains an ambiguity from published data as to which site and side should be the first choice for vascular access placement and what interaction this has with patient factors and timing. Early consideration of tunnelled semi-permanent access may provide optimal filter life if longer periods of CRRT are anticipated. There remains an absence of robust evidence outside of anti-coagulation strategies despite over 20 years of therapy delivery however trends favour CVVHD-F over CVVH.