Key result
Anticoagulation-free continuous renal replacement therapy in critically ill patients at high bleeding risk yielded a similar filter lifespan compared to systemic heparin (WMD -1.55 hours), but was inferior to regional citrate anticoagulation.
Why the study?
Guidelines recommend CRRT without anticoagulation in patients with increased bleeding risk and contraindications to citrate, but the efficacy of anticoagulation-free CRRT remains inconsistent.
Does anticoagulation-free CRRT improve filter lifespan and safety compared to systemic heparin, regional citrate anticoagulation, or nafamostat in critically ill patients at high risk of bleeding?
Systemic Review (n=1,615)
Does anticoagulation-free CRRT improve filter lifespan and safety compared to systemic heparin, regional citrate anticoagulation, or nafamostat in critically ill patients at high risk of bleeding?
Mean Difference: -1.55 (95% CI -3.71–0.6)
p-value: p=0.15
In critically ill patients at high bleeding risk, anticoagulation-free CRRT yields similar filter lifespan to systemic heparin, but regional citrate anticoagulation provides superior filter lifespan and is the optimal choice if not contraindicated.
Regional citrate anticoagulation extends CRRT filter lifespan versus anticoagulation-free protocols; supports consideration in high-bleeding-risk patients but requires larger RCTs.
The current clinical guideline recommends continuous renal replacement therapy (CRRT) proceed without anticoagulation in patients with contraindication to citrate and increased bleeding risk. Nevertheless, the efficacy of anticoagulation‐free CRRT remains inconsistent. The purpose of our present systematic review is to evaluate the efficacy and safety of anticoagulant‐free CRRT based on the current literatures. The primary outcomes were filter lifespan and risk factors for filter failure. Seventeen observational studies and three randomized controlled trials were included in our present meta‐analysis. There was no significant difference in filter lifespan and azotemic control between the anticoagulation‐free and systemic heparin group. The regional citrate anticoagulation (RCA) protocol seems to be superior to the anticoagulation‐free protocol in terms of filter lifespan (WMD −23.01, 95% CI [−28.62, −17.39], p < 0.001; I 2 = 0%, p = 0.53) and azotemic control. Nafamostat protocol could significantly prolong filter lifespan (WMD −8.4, 95% CI [−9.9, −6.9], p < 0.001; I 2 = 33.7%, p = 0.21) as compared with anticoagulation‐free protocol without better azotemic control. The conventional coagulation parameters showed poor predictive performence for filter failure and the necessity of anticoagulants use before CRRT. Currently, the optimal choice of anticoagulation strategy for critically ill patients with increased bleeding risk could be RCA under close monitoring.
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Zhang et al. (2021) conducted a systemic review in Acute kidney injury requiring continuous renal replacement therapy with high risk of bleeding (n=1,615). Anticoagulation-free continuous renal replacement therapy vs. Systemic heparin, regional citrate anticoagulation, or nafamostat was evaluated on Filter lifespan (anticoagulation-free vs systemic heparin) (WMD -1.55, 95% CI -3.71, 0.60, p=0.15). Anticoagulation-free continuous renal replacement therapy in critically ill patients at high bleeding risk yielded a similar filter lifespan compared to systemic heparin (WMD -1.55 hours), but was inferior to regional citrate anticoagulation.
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