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
局部枸橼酸抗凝（RCA）广泛应用于持续肾脏替代治疗（CRRT）。目前大多数指南的推荐将肝衰竭作为枸橼酸抗凝禁忌症之一。然而，有研究表明，肝衰竭患者在CRRT时使用枸橼酸并未增加枸橼酸相关并发症的风险。本系统回顾目的是总结目前CRRT时RCA对于肝衰竭患者的安全性和有效性的证据。
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
我们综合搜索PubMed，Embase和Cochrane Library数据库从最初到2018年3月1日的数据。本系统回顾纳入了接受RCA-CRRT的不同程度肝功能异常的成年（年龄>18岁）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.
结果
研究筛选后，本系统回顾共纳入10个观察性研究1241肝功能异常患者。枸橼酸蓄积和出血发生率分别为12%（3%，22%）和5%（2%，8%）。与基线数据相比，观察结束时血清pH值，碳酸氢盐，碱剩余，代谢性碱中毒发生率，血清离子钙和总钙水平，以及总钙与离子钙的比值均显著增加。然而，在CRRT结束后，没有观察到血清中柠檬酸（MD −65.82 [−194.19，62.55]），乳酸（MD 0.49 [−0.27，1.26]）和总胆红素浓度（MD 0.79 [−0.70，2.29]）有显著增加。与非肝衰竭患者相比，肝衰竭患者CRRT治疗过程中，pH值（MD −0.04 [−0.13，0.05]），血清乳酸水平（MD 0.69 [−0.26，1.64]）和总钙/离子钙比率（MD 0.03 [−0.12，0.18]）均没有明显差异。
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.
结论
RCA在肝衰竭患者进行CRRT治疗时似乎是一个安全的抗凝方法，而且能产生良好的滤器寿命。在肝衰竭患者进行RCA-CRRT时，密切监测酸碱状态和电解质平衡可能更有必要。
北京市昌平区医院 沙伟伟译
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