Efficacy and safety of regional citrate anticoagulation in critically acute kidney injury patients undergoing continuous renal replacement; a systematic review

Abstract

Background: Critically ill patients with an acute kidney injury (AKI) require renal replacement therapy (RRT), with the preferred method which is continuous renal replacement therapy (CRRT). Globally, systematic heparin is the most used form of anticoagulant, which is often required to prevent extracorporeal circuit and filter clotting in patients undergoing CRRT. However, this can increase the risk of bleeding incidences and the possibility of heparin-induced thrombocytopenia (HIT). Regional citrate anticoagulation (RCA) is an alternative method for heparin, which can reduce these issues. Aim: This systematic review was conducted to evaluate the efficacy and safety of regional citrate anticoagulation compared with systematic heparin, on the circuit lifespan, adverse events, and cost-effectiveness. Method: The PubMed database was used to search for eligible studies, and manual searches were also conducted to identify additional trials, which were undertaken on the 1st of July 2021 for randomised controlled trials (RCTs). In these studies, patients with high risk of bleeding or liver failure were excluded; in which the RCTs assessed the effectiveness and safety of regional citrate compared to heparin in adult patients with AKI who required CRRT. The risk of bias was assessed by using the Cochrane (ROB) Tools for Randomized Controlled Studies Results: Six studies were included with 1466 patients who met the inclusion criteria, which involved more than 1359 circuits. RCA is a safe and effective treatment which can prolong the filter life span significantly compared to systematic heparin. In addition, bleeding complications and clotting incidences were fewer in the RCA as well. However, metabolic adverse events and citrate accumulation were more associated with citrate anticoagulation, such as alkalosis, hypocalcaemia. Nonetheless, cost-effectiveness was controversial among studies.