连续性肾脏替代治疗中局部枸橼酸抗凝与全身肝素抗凝比较的Meta分析  

Regional citrate versus heparin anticoagulation in continuous renal replacement therapy in critically ill patients:a Meta-analysis

作　　者：冯璇璘[1] 邓磊[1] 张洋 常莉[1] Feng Xuanlin;Deng Lei;Zhang Yang;Chang Li(Department of EICU,Sichuan Academy of Medical Sciences&Sichuan People's Hospital,Chengdu 610072,Sichuan,China)

机构地区：[1]四川省医学科学院·四川省人民医院急诊ICU,成都610072

出　　处：《中华危重病急救医学》2020年第8期982-987,共6页Chinese Critical Care Medicine

基　　金：四川省医药卫生科研课题(18PJ319)。

摘　　要：目的通过Meta分析比较局部枸橼酸抗凝与全身肝素抗凝在重症患者连续性肾脏替代治疗(CRRT)中的优劣和安全性差异.方法计算机检索和手工检索Medline、Embase、Cochrane图书馆、Web of Science、中国知网和万方数据库自建库至2019年12月发表的,有关CRRT中局部枸橼酸抗凝与全身肝素抗凝比较的随机对照试验(RCT),语种为英文或中文.主要研究结果为病死率和滤器寿命;次要结果为出血、肝素诱导性血小板减少(HIT)、代谢性碱中毒和低钙血症等并发症.按Cochrane系统评价的方法筛选文献,采用RevMan 5.3软件对数据进行Meta分析,并用漏斗图分析各研究间病死率和并发症是否存在发表偏倚.结果共纳入16篇文献、1229例患者.Meta分析显示,CRRT时局部枸橼酸抗凝与全身肝素抗凝对重症患者病死率影响差异无统计学意义〔相对危险度(RR)=0.95,95%可信区间(95%CI)为0.83~1.09,P=0.47〕,但局部枸橼酸组滤器寿命较全身肝素组延长了15.37 h(95%CI为10.09~20.65,P<0.00001).局部枸橼酸组出血风险和HIT发生率均低于全身肝素组(出血:RR=0.29,95%CI为0.19~0.44,P<0.00001;HIT:RR=0.35,95%CI为0.16~0.74,P=0.006),但局部枸橼酸抗凝可引起低钙血症(RR=4.67,95%CI为1.88~11.60,P=0.0009).两组代谢性碱中毒发生率差异无统计学意义(RR=0.76,95%CI为0.42~1.37,P=0.36).漏斗图显示,纳入研究无明显发表偏倚.结论局部枸橼酸抗凝可有效延长滤器寿命,减少出血风险,可作为重症患者CRRT治疗的优先选择.Objective To evaluate the efficacy and safety of regional citrate and heparin anticoagulation in continuous renal replacement therapy(CRRT)in critically ill patients by Meta-analysis.Methods Randomized controlled trials(RCT)comparing the efficacy and safety of regional citrate and heparin anticoagulation in English or Chinese were retrieved from Medline,Embase,Cochrane library,Web of Science,CNKI,Wanfang Database by electronic and manual search before December 2019.The primary outcomes were mortality and circuit life span,and the secondary outcomes were complications such as bleeding,heparin-induced thrombocytopenia(HIT),metabolic alkalosis,and hypocalcemia.Meta-analysis of the literature was conducted using the methods recommended by the Cochrane Collaboration's software RevMan 5.3 and funnel plot was used to analyze whether there was publication bias in each study.Results Sixteen RCTs with 1229 patients were included.Meta-analysis showed that there was no significant difference in mortality between the regional citrate and heparin anticoagulation in CRRT[relative risk(RR)=0.95,95%confidence interval(95%CI)was 0.83-1.09,P=0.47].The circuit life span in the regional citrate group was 15.37 hours(95%CI was 10.09-20.65,P<0.00001)longer than that in the heparin group.Bleeding risk(RR=0.29,95%CI was 0.19-0.44,P<0.00001)and HIT(RR=0.35,95%CI was 0.16-0.74,P=0.006)were lower in the regional citrate group than those in the heparin group,whereas the regional citrate anticoagulation could cause hypocalcemia(RR=4.67,95%CI was 1.88-11.60,P=0.0009).There was no significant difference in the incidence of metabolic alkalosis between the two groups(RR=0.76,95%CI was 0.42-1.37,P=0.36).The funnel plot showed that there were no significant publication bias in the included studies.Conclusion Regional citrate anticoagulation could significantly prolong circuit life span and decrease the risk of bleeding,and should be preferentially selected for the CRRT anticoagulation in critically ill patients.

关 键 词：枸橼酸 肝素 连续性肾脏替代治疗 抗凝 META分析 

分 类 号：R692[医药卫生—泌尿科学]