Sriram Sunil, MBBS
Physician
Bangalore Medical College, United States
Disclosure information not submitted.
Emerson Ridley, MD
Resident
Emory University
decatur, Georgia, United States
Disclosure information not submitted.
John Davis, MD
Resident
Emory University
decatur, Georgia, United States
Disclosure information not submitted.
Thara Vidyasagaran, MD
Assistant Professor
Emory University
decatur, Georgia, United States
Disclosure information not submitted.
Jonathan Suarez, MD
Assistant Professor
Emory University, United States
Disclosure information not submitted.
Jason Cobb, MD
Associate Professor
Emory University
decatur, Georgia, United States
Disclosure information not submitted.
Title: Citrate vs Heparin anticoagulation strategy in continuous renal replacement therapy - A metaanalysis
Introduction: Acute Kidney Injury (AKI) is very common in the ICU setting, it occurs in approximately 50% of patients, and about 15% require renal replacement therapy. Although RCTs have failed to demonstrate a clear benefit with mortality or renal recovery, continuous renal replacement therapy (CRRT) has been widely used to achieve adequate volume and metabolic control in critically ill patients. Guidelines recommend the use of anticoagulation for successful administration of CRRT and several trials have compared the efficacy of citrate versus heparin. In our study, we have analyzed the data from various studies to evaluate which of the two strategies is better.
Methods: We searched online databases for RCTs comparing citrate and heparin as anticoagulants in CRRT, and found 11 RCTs that met inclusion criteria, and the data was used in the qualitative synthesis. Statistical analysis was done using RevMan 5.3.
Results: A total of 11 RCTs were included with 783 patients in citrate group and 785 in heparin group. 11 studies evaluated filter life and it was significantly higher with citrate use (MD 21.16 95% CI 11.60, 30.72 P< 0.0001). Morality was reported in 8 studies and there was no difference between the groups (OR 0.93 95% CI 0.75, 1.15 P 0.50). Incidence of bleeding was significantly lower in the citrate group (OR 0.30 95%CI 0.20,0.44 P< 0.00001). Incidence of hypocalcemia was evaluated in 8 studies and was significantly higher with citrate (OR 3.88 95%CI 1.60,9.40, P=0.03). Incidence of heparin-induced thrombocytopenia (6 studies) or metabolic alkalosis (7 studies) did not show any difference between the groups (OR 0.61 95%CI 0.32,1.16 P=0.13) and (OR 1.73 95%CI 0.50,5.97 P=0.38) respectively.
Conclusion: Citrate chelates calcium and blocks multiple steps in the coagulation cascade, and renders blood to remain in a fluid state, making it a suitable anticoagulant in blood bags and CRRT circuits. Our meta-analysis demonstrates that the use of regional citrate increases filter life span with significantly lesser bleeding risk. While we observed an increased incidence of hypocalcemia in the citrate group, our results suggest that with careful monitoring of the metabolic panel, citrate can be safely used to successfully administer CRRT without major risks.