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

Abstract

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.

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.

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 live 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.

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.

Keywords: Anticoagulation; Citrate; Continuous renal replacement therapy; Liver failure.

Conflict of interest statement

Ethics approval and consent to participate

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Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Study inclusion flow chart
Fig. 2
Fig. 2
The pooled rates (95% CI) of filter clotting (a) and citrate accumulation (b), and the pooled MDs of totCa/ionCa ratio (c) and serum citrate level (d) between the start of CRRT and the end of observation. CI, confidence interval; ionCa, ionized calcium; MD, mean difference; M, mild liver failure group; S, Severe liver failure group; totCa, total calcium
Fig. 3
Fig. 3
The pooled rates of bleeding (a) and the pooled MDs of total bilirubin (b), pH (c), and serum bicarbonate (d) between the start of CRRT and the end of observation. CI, confidence interval; G1 group 1, G2 group 2, G3 group 3, G4 group 4; MD, mean difference; M, mild liver failure group; S, Severe liver failure group

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