Meta分析:连续性肾替代治疗中枸橼酸抗凝与肝素抗凝方法的比较

Meta analysis:a comparison of methods in CRRT citrate anticoagulation with heparin anticoagulation method

目的对近年来有关临床随机对照试验结果进行总结,比较连续性肾替代治疗（continuous renal replacement treatment,CRRT）中枸橼酸与肝素抗凝的优劣和安全性。方法对随机对照试验进行系统回顾和荟萃分析。研究对象设定为进入ICU、伴有急性肾损伤和（或）重度脓毒症的患者。研究的选择标准限于随机对照试验研究,对文章的语言不做限制,有入选的非英语文献请专业的机构进行翻译。对CRRT时局部枸橼酸与肝素抗凝进行比较。终点：首要终点是CRRT滤器的使用时间、凝血功能障碍引起的大出血（定义为血压下降或需要≥2个单位的红细胞输注）,以及代谢性碱中毒、低钙血症、血小板减少症;次要终点是医疗费用高昂超过患者的负担。结果纳入6个随机对照试验（362例患者）。枸橼酸抗凝是出血减少的影响因素（RR=0.230,95%CI=0.100-0.530）,肝素在电解质紊乱和酸碱平衡紊乱方面有着更低的发生率（RR=4.310,95%CI=1.450-12.860）,两者在滤器寿命方面差异无统计学意义（95%CI=0.810-1.160）,局限性：样本例数不均衡、文献质量不高。结论枸橼酸能够降低抗凝时的出血风险,但会显著增加电解质和代谢异常的发生率。

Objective To analyze recent randomized controlled trials（RCT）,to compare the benefit and defect as well as safety of citrate anticoagulation with heparin anticoagulation method in continuous renal replacement treatment（CRRT）.Methods A systematic review and Metaanalysis was performed to RCT.Research involved intensive care unit（ICU）admitting patients with acute kidney injury and/or in severe sepsis.Selection criteria included the studies limited to RCT researches,the language did not limit,the non English literature were translated by professionals.Comparison was made in regional citrate anticoagulation with heparin on intervention CRRT.Termination：the primary end points were the time of CRRT filter,major bleeding caused by coagulopathy（defined as a drop in blood pressure or need more than 2 units of red blood cell transfusion）and metabolic alkalosis,hypocalcaemia,thrombocytopenia;secondary end points were the high medical costs more than the burden of patients.Results Six RCT（362 patients）were included.Citrate anticoagulation was a factor to reduce bleeding（RR=0.230,95%CI=0.100-0.530）.Heparin had a much lower incidence in the electrolyte imbalance and acid-base balance disorder（RR=4.310,95%CI=1.450-12.860）,the two methods showed no significant difference in the life time of filter（95%CI=0.810-1.160）.Limitation：the number of sample not balanced and document quality not high.Conclusion Citrate anticoagulation can reduce bleeding risk,but will significantly increase the electrolyte and the incidence of metabolic abnormalities.