Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

BMC Nephrology

Research Article

Elizabeth Winson¹  John McNeil²  Owen Roodenburg³  Matthew Brain⁴ 

[1] Launceston General Hospital, Launceston, TAS, Australia;School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia;School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia;The Alfred Intensive Care Unit, Melbourne, VIC, Australia;School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia;The Alfred Intensive Care Unit, Melbourne, VIC, Australia;Launceston General Hospital, Launceston, TAS, Australia;

关键词: Continuous renal replacement therapy;    CRRT;    Vascular access;    Filter life;    Femoral;    Jugular;    Vein;   

DOI  :  10.1186/s12882-017-0445-5

 received in 2016-09-10, accepted in 2017-01-10,  发布年份 2017

来源: Springer

【 摘 要 】

ndOptimising filter life and performance efficiency in continuous renal replacement therapy has been a focus of considerable recent research. Larger high quality studies have predominantly focussed on optimal anticoagulation however CRRT is complex and filter life is also affected by vascular access, circuit and management factors. We performed a systematic search of the literature to identify and quantify the effect of vascular access, circuit and patient factors that affect filter life and presented the results as a meta-analysis.MethodsA systematic review and meta-analysis was performed by searching Pubmed (MEDLINE) and Ovid EMBASE libraries from inception to 29th February 2016 for all studies with a comparator or independent variable relating to CRRT circuits and reporting filter life. Included studies documented filter life in hours with a comparator other than anti-coagulation intervention. All studies comparing anticoagulation interventions were searched for regression or hazard models pertaining to other sources of variation in filter life.ResultsEight hundred nineteen abstracts were identified of which 364 were selected for full text analysis. 24 presented data on patient modifiers of circuit life, 14 on vascular access modifiers and 34 on circuit related factors. Risk of bias was high and findings are hypothesis generating.Ranking of vascular access site by filter longevity favours: tunnelled semi-permanent catheters, femoral, internal jugular and subclavian last. There is inconsistency in the difference reported between femoral and jugular catheters.Amongst published literature, modality of CRRT consistently favoured continuous veno-venous haemodiafiltration (CVVHD-F) with an associated 44% lower failure rate compared to CVVH. There was a trend favouring higher blood flow rates. There is insufficient data to determine advantages of haemofilter membranes.Patient factors associated with a statistically significant worsening of filter life included mechanical ventilation, elevated SOFA or LOD score, elevations in ionized calcium, elevated platelet count, red cell transfusion, platelet factor 4 (PF-4) antibodies, and elevated fibrinogen.Majority of studies are observational or report circuit factors in sub-analysis. Risk of bias is high and findings require targeted investigations to confirm.ConclusionThe interaction of patient, pathology, anticoagulation, vascular access, circuit and staff factors contribute to CRRT filter life. There remains an ambiguity from published data as to which site and side should be the first choice for vascular access placement and what interaction this has with patient factors and timing. Early consideration of tunnelled semi-permanent access may provide optimal filter life if longer periods of CRRT are anticipated. There remains an absence of robust evidence outside of anti-coagulation strategies despite over 20 years of therapy delivery however trends favour CVVHD-F over CVVH.

【 授权许可】

CC BY   
© The Author(s). 2017