Background
Methods
Search strategy and information sources
Inclusion and exclusion criteria
Study selection and data extraction
Quality assessment
Grading quality of evidence
Statistical analysis
Trial sequential analysis
Results
Study enrolment and characteristics
Source | Setting | Exclusion | Patients (M/F)/circuits, number | Mean age, years | Severity | Modality; dilution; blood flow (ml/min) | Filter material |
---|---|---|---|---|---|---|---|
Stucker et al. [11] (2015; CH) | ICU of the university hospitals | Cirrhosis, severe coagulopathy, high risk of bleeding and sensitivity to heparin | C: 54 (32/22)/NR | C: 60 ± 14a
| C: 28 ± 9 (APACHE II)/63 ± 18 (SAPS)a
| CVVHDF; 2/3 pre-dilution and 1/3 post-dilution; 100–200 | 1.5 m2 High-flux membrane |
H: 49 (32/17)/NR | H: 65 ± 16a
| H: 29 ± 9 (APACHE II)/65 ± 18 (SAPS)a
| |||||
Gattas et al. [12] (2015; AU) | Seven different ICUs | Liver failure, pregnant or breastfeeding, HIT, chronic dialysis | C: 105 (74/31)/390 | C: 66.4 ± 14.3a
| C: 25.6 ± 7.6 (APACHE II)a
| CVVHDF (61 %) CVVH (29 %); pre-dilution; 150 (52 %) 200 (23 %) | Aquarius or Prismaflex |
H: 107 (72/35)/467 | H: 66.8 ± 14.9a
| H: 25.0 ± 6.9 (APACHE II)a
| |||||
Schilder et al. [13] (2014; NL) | Ten different ICUs | High bleeding risk, other Therapeutic anticoagulation, HIT | C: 66 (44/22)/NR | C: 67 (36–87)b
| C: 23 (11–53) (APACHE II)/10 (2–19) (SOFA)b
| CVVH; pre-dilution; 180 | NR |
H: 73 (49/24)/NR | H: 67 (23–85)b
| H: 25 (6–43) (APACHE II)/11 (3–18) (SOFA)b
| |||||
Brain et al. [25] (2014; AU) | A large metropolitan ICU | Contraindication to citrate or heparin, pregnancy, or lactation | C: 19 (12/7)/96 H: 11 (7/4)/125 | C: 64 ± 13a
H: 51 ± 17a
| C: 80 (58–99) (APACHE III)b
H: 61 (52.5–91.5) (APACHE III)b
| CVVHDF; pre-dilution; mean 191 (citrate) and 217 (heparin) | ST-100 (68.8 %); ST-150 (7.2 %); M100 (20.8 %); others (3.2 %) |
Monchi et al. [27] (2004; BE) | 32-Bed medical and surgical ICU | Cirrhosis, severe coagulopathy, high risk of bleeding | C: 8 (NR)/26 | C: 67 (52–77)b
| C: 40 (31–53) (SAPS)b
| CVVH; post-dilution; 175 | 1.6 m2 Highly permeable PS membrane |
H: 12 (/NR)/23 | H: 64 (52–74)b
| H: 42 (33–55) (SAPS)b
| |||||
Lin XM et al. [29] (2007; CN) | Adult mixed ICU | NR | C: 27 (16/11)/NR | C: 63 ± 21a
| C: 82.5 ± 22.4 (APACHE III)a
| CVVHDF; pre-dilution; 100–180 | PRISMA M-100 AN69 |
H: 23 (14/9)/NR | H: 64 ± 19a
| H: 75.6 ± 18.3 (APACHE III)a
| |||||
Cui W et al. [30] (2011; CN) | Adult mixed ICU | NR | C: 23 (12/11)/NR | C: 46.9 ± 6.1a
| C: NR | CVVH; NR; NR | PRISMA |
H: 23 (13/10)/NR | H: 47.2 ± 5.9a
| H: NR | |||||
Yang ST et al. [31] (2014; CN) | Adult mixed ICU | severe coagulopathy, high risk of bleeding | C: 25 (NR)/81 | 61.7 ± 8.6 | C: NR | CVVH; pre-dilution; 200–250 | Aquarius, HF1200 |
H: 21 (NR)/53 | H: NR | ||||||
Oudemans-van Straaten et al. [28] (2009; NL) | ICU of a teaching hospital | Cirrhosis, bleeding, HIT, chronic dialysis, Contraindication to citrate or heparin | C: 97 (66/31)/NR | C: 73 (67–79)b
| C: 28 (27–30) (APACHE II)/59 (55–62) (SAPS)b
| CVVH; post-dilution; 220 | 1.9 m2 Cellulose triacetate hollow fibre membrane |
N: 103 (70/33)/NR | N: 73 (67–79)b
| N: 8 (27–29) (APACHE II)/61 (58–64) (SAPS)b
| |||||
Betjes et al. [24] (2007; NL) | Adult mixed ICU | HIT, severe coagulopathy, high risk of bleeding, severe circulatory shock and liver failure | C: 1 (15/6)/70 | C: 57.8 ± 4.2a
| C: 51.4 ± 4.1 (SAPS)a
| CVVH;post-dilution; 150 | High-flux triacetate |
H: 27 (19/8)/72 | H: 55.2 ± 2.8a
| H: 51.0 ± 2.6 (SAPS)a
| |||||
Fealy et al. [26] (2007; AU) | ICU of tertiary hospital | Liver failure, hepatitis and contraindication to citrate or heparin | C:10 (9/1)/10 | 71 (63.5–76.5)b
| SAPS: 41 (31–43) APACHE II:17 (15–21)b
| CVVH; pre-dilution; 150 | APS650 PS hollow fibre membrane |
H:10 (9/1)/10 | |||||||
Kutsogiannis et al. [34] (2005; CA) | Tertiary and community hospital ICU | Liver failure, Contraindication to citrate or heparin | C: 16 (7/9)/36 | C: 66.5 ± 14.5a
| C: 7.75 ± 3.53 (OD)a
| CVVHDF; pre-dilution; 125 | Standard PRISMA M-100 AN69 |
H: 14 (8/6)/43 | H: 63.9 ± 21.2a
| H: 9.42 ± 2.31 (OD)a
| |||||
Tiranathanagul et al. [32] (2011; TH) | Adult mixed ICU | Severe hepatitis and cirrhosis, hypercalcaemia, Contraindication to citrate or heparin, other therapeutic anticoagulation | C: 10 (5/5)/NR | C: 69.5(32–78)b
| C: 21 (18–29) (APACHE II)b
| CVVH; pre-dilution; 120 | 1.5 m2 Polyethersulfone dialyzers |
H: 10 (7/3)/NR | H: 75.5 (18–87)b
| H: 22 (15–29) (APACHE II)b
| |||||
Hetzel et al. [33] (2011; DE) | Nine different ICUs | Contraindication to citrate or heparin, metabolic, alkalosis, pregnancy or lactation, chronic dialysis, other therapeutic, anticoagulation, HIT | C: 87 (57/30)/NR | C: 62 ± 15.3a
| C: 21.8 ± 5.1 (APACHE II) | CVVH; pre-dilution; HF-solution flow 3:1 | AV600S high-flux membrane |
9.95 ± 2.9 (SOFA)a
| |||||||
H: 83 (59/24)/NR | H: 65 ± 12.5a
| H: 22.04 ± 5.5 (APACHE II) | |||||
9.95 ± 2.6 (SOFA)a
|
Quality of studies
Primary outcomes
Mortality
Circuit life span
Secondary outcomes
Adverse events
Adverse events | No. of studies | No. of patients | RR(95%CI) | Heterogeneity | Test for effect (p value) | |
---|---|---|---|---|---|---|
Citrate | Heparin | I2 (p value) | ||||
Bleeding events | 10 (11, 13, 24, 25, 27, 28, 29, 32, 33, 34)a
| 405 | 405 | 0.31(0.19, 0.51) | 0% (0.56) | <0.00001 |
3 (12, 26, 31)b
| 140 | 138 | 0.23 (0.03, 1.97) | 0% (0.75) | 0.18 | |
HIT | 5 (11, 12, 13, 28, 33) | 409 | 415 | 0.41 (0.19, 0.87) | 0% (0.73) | 0.02 |
Metabolic alkalosis | 7(11, 13, 24, 27, 28, 29, 34) | 289 | 301 | 0.84 (0.47, 1.49) | 40% (0.14) | 0.55 |
Hypocalcemia | 7 (11, 24, 27, 28, 29, 33, 34) | 310 | 311 | 3.96 (1.50, 10.43) | 0% (1.00) | 0.005 |
Cost-effectiveness
Inflammatory cytokines
Publication bias
Discussion
Conclusion
Key messages
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Patient mortality was similar for regional citrate and heparin anticoagulation during CRRT in the critically ill patient with AKI, which was confirmed by TSA
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RCA significantly prolonged the circuit life span in both the CVVH subgroup and pre-dilution subgroup, although the TSA did not confirm this result
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Compared with systemic heparin, RCA significantly decreased the bleeding risk, and the result was confirmed by TSA