Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials.
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.


METHODS
Systematic review and meta-analysis of randomized controlled trials (RCTs).


METHODS
Patients admitted to the intensive care unit with acute kidney injury that required CRRT.


METHODS
RCTs regardless of publication status or language.


METHODS
Regional citrate versus heparin anticoagulation in CRRT.


RESULTS
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.


CONCLUSIONS
Significant heterogeneity in the primary outcome.


CONCLUSIONS
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.
Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan.
Mei-Yi
MY
Wu
Yung-Ho
YH
Hsu
Chyi-Huey
CH
Bai
Yuh-Feng
YF
Lin
Chih-Hsiung
CH
Wu
Ka-Wai
KW
Tam
D058186:Acute Kidney Injury / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D002951:Citrates / Q000009:adverse effects / Q000627:therapeutic use*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D017582:Renal Replacement Therapy / Q000009:adverse effects / Q000379:methods*; D018570:Risk Assessment; D015996:Survival Rate; D013927:Thrombosis / Q000517:prevention & control; D016896:Treatment Outcome
D000925:Anticoagulants; D002951:Citrates; D006493:Heparin