Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials

Wu, Mei-Yi; Hsu, Yung-Ho; Bai, Chyi-Huey; Lin, Yuh-Feng; Wu, Chih-Hsiung; Tam, Ka-Wai

doi:10.1053/j.ajkd.2011.11.030

« Previous Next »American Journal of Kidney Diseases
Volume 59, Issue 6 , Pages 810-818, June 2012

Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomized Controlled Trials

Mei-Yi Wu, MD
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
Yung-Ho Hsu, MD
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
Chyi-Huey Bai, PhD
- School of Public Health, Taipei Medical University, Taipei, Taiwan
Yuh-Feng Lin, MD
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
Chih-Hsiung Wu, MD, PhD
- Division of General Surgery, Department of Surgery, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
Ka-Wai Tam, MD, MS
- Division of General Surgery, Department of Surgery and Evidence-Based Medicine Center, Taipei Medical University Hospital, Taipei, Taiwan
- Address correspondence to Ka-Wai Tam, MD, MS, Department of Surgery, Taipei Medical University Hospital, 252 Wuxing St, Taipei 11031, Taiwan

Received 25 July 2011; accepted 1 November 2011. published online 09 January 2012.

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.

Study Design

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

Setting & Population

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

Selection Criteria for Studies

RCTs regardless of publication status or language.

Intervention

Regional citrate versus heparin anticoagulation in CRRT.

Outcomes

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.

Limitations

Significant heterogeneity in the primary outcome.

Conclusion

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.

Index Words: Citrate , heparin , anticoagulation , continuous renal replacement therapy , meta-analysis