The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, Shaanxi, China.
State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, 28th Fuxing Road, Beijing, 100853, China.
Crit Care. 2019 Jan 24;23(1):22. doi: 10.1186/s13054-019-2317-9.
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.
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.
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.
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.
局部枸橼酸抗凝（RCA）是连续肾脏替代治疗（CRRT）中广泛应用的策略。目前大多数指南都将肝功能衰竭列为枸橼酸抗凝的禁忌证之一。然而，一些研究表明，在肝功能衰竭患者中使用枸橼酸进行 CRRT 并未增加枸橼酸盐相关并发症的风险。本系统评价的目的是总结目前关于肝功能衰竭患者 RCA-CRRT 的安全性和有效性的证据。
我们在 PubMed、Embase 和 Cochrane 图书馆数据库中全面检索了从创建到 2018 年 3 月 1 日的文献。本系统评价纳入了接受 RCA-CRRT 的各种肝功能障碍的成年（年龄＞18 岁）患者的研究。
经过研究筛选，10 项观察性研究共纳入 1241 例肝功能障碍患者，纳入本系统评价。枸橼酸盐蓄积和出血的累积发生率分别为 12%[3%，22%]和 5%[2%，8%]。与基线数据相比，观察结束时血清 pH、碳酸氢盐、碱剩余（BE）、代谢性碱中毒发生率、血清离子钙（ionCa）和总钙（totCa）水平以及总钙/离子钙（totCa/ionCa）比值显著升高。然而，CRRT 结束时，血清枸橼酸盐（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]）均无明显增加。与非肝功能衰竭患者相比，肝功能衰竭患者在 CRRT 期间 pH（MD-0.04[-0.13，0.05]）、血清乳酸水平（MD 0.69[-0.26，1.64]）和 totCa/ionCa 比值（MD 0.03[-0.12，0.18]）均无显著差异。平均滤器寿命的中位数为 55.9 小时，范围为 22.7 至 72 小时。
局部枸橼酸抗凝似乎是肝功能衰竭患者行 CRRT 的一种安全抗凝方法，并且可以获得良好的滤器寿命。在肝功能衰竭患者中进行 RCA-CRRT 时，更有必要密切监测酸碱状态和电解质平衡。
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