Efficacy and safety of regional citrate anticoagulation for artificial liver support in patients with liver failure: A meta-analysis

  Background  The application of regional citrate anticoagulation in artificial liver support therapy for patients with liver failure is still controversial.

  Objective  To systematically evaluate the efficacy and safety of regional citrate anticoagulation (RCA) for artificial liver support in patients with liver failure.

  Methods  Studies about RCA for artificial liver support in patients with liver failure were retrieved in PubMed, Embase, the Cochrane Library, CNKI, Wanfang data and SinoMed from their foundation to February 2020. The literature screening and data extraction were performed by two researchers independently. Meta-analysis was performed by Medcalc15.6.1 for non-comparative binary data and continuous variable data before and after treatment, and by Stata/SE 15.1 for a single set of continuous variables.

  Results  A total of 8 articles that met the inclusion criteria were included, including 2 in Chinese and 6 in English. Research quality assessment showed that there were 7 high quality studies and 1 moderate quality study. Six hundred and fifty-nine artificial liver support sessions performed in 211 patients were enrolled in analysis. In terms of efficacy, the completion rate of artificial liver treatment with RCA was 94.2% (95% CI: 90.7% - 96.9%, I² = 50.2%), the incidence of interruption of artificial liver support due to occlusive clotting of the extracorporeal circuit was 4.7% (95% CI: 2.7% - 7.2%, I² = 25.7%), the decrease rate of serum total bilirubin before and after artificial liver treatment was 41.2% (95% CI: 31.9% - 50.5%, I² = 97.8%). In terms of safety, the incidence of hemorrhage during the artificial liver support with RCA was 1.25% (95% CI: 0.47% - 2.66%, I² = 23.57%), and the incidence of citrate accumulation was 25.7% (95% CI: 7.5% - 50.0%, I² = 94.5%). After the end of artificial liver support, systemic ionized calcium concentrations decreased compared with that before treatment, and returned to the pre-treatment level in 2 hours. There was no significant change in pH before and after artificial liver support. The liver failure patients who underwent artificial liver therapy with RCA obtained a survival rate of 51.3% (95% CI: 41.7% - 60.8%, I² = 0).

  Conclusion  It is safe and effective of RCA for artificial liver support in the patients with liver failure, but there is still a risk of citrate accumulation that require more attention by the clinicians.