Ming Bai

Introduction: Regional citrate anticoagulation (RCA) is increasingly utilized for therapeutic plasma exchange (TPE). Currently, many clinical studies have focused on the safety and efficacy of RCA in TPE. However, due to the complex application and the lack of a uniform standard of RCA, the results of these researches, especially citrate‐related metabolic complications, varied greatly in different studies. The purpose of this meta‐analysis is to assess the safety and efficacy of RCA in TPE. Methods: We performed a comprehensive search on PubMed, Embase, and the Cochrane Library database from the inception to August 26, 2024. Studies regarding the application of RCA in TPE were included to assess the efficacy and safety of RCA in TPE. The methodological quality of the included studies was assessed using the Newcastle‐Ottawa Scale and the Jadad scale. Meta‐analysis was performed using Stata software (version 15.1). Results: There were 13 eligible studies included, involving 4268 RCA–TPE sessions. The pooled rate of extracorporeal circuit clotting, bleeding, citrate accumulation, hypocalcemia, hypernatremia, hypomagnesemia, and metabolic alkalosis was 5.3% (95% CI [2.4–9.2]), 2.0% (95% CI [0.2–5.0]), 1.8% (95% CI [0.0–6.7]), 17.9% (95% CI [2.3–42.5]), 1.7% (95% CI [0.0–5.1]), 45.6% (95% CI [25.9–66.0]), and 14.8% (95% CI [0.5–41.3]), respectively. Subgroup analysis of hypocalcemia and metabolic alkalosis in the membrane therapeutic plasma exchange (mTPE) was 42.1% (95% CI [2.5–89.7]) and 32.4% (95% CI [25.3–39.9]), respectively. Compared to before treatment, the serum sodium and bicarbonate significantly increased, and serum calcium decreased significantly after RCA–TPE treatment. There was no difference in platelet (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), the ratio of total calcium to ionized calcium, total calcium, pH, and base excess (BE) before and after treatment. Subgroup analyses demonstrated that pH and BE in mTPE, and APTT and PT in double filtration plasmapheresis (DFPP) were significantly increased after treatment. Conclusion: Regional citrate anticoagulation might be effective in TPE treatments. However, the incidence of hypomagnesemia, hypocalcemia, and metabolic alkalosis is relatively high. Close monitoring and timely adjustment are needed during the process of RCA–TPE treatment to avoid these complications.

Introduction Two techniques are commonly used for the femoral artery puncture closure during decannulation in venoarterial extracorporeal membrane oxygenation (V-A ECMO): the conventional post-closure technique and the small-sheath technique, also referred to as the area-decreasing technique. To date, no standardised protocol has been established for femoral artery closure following V-A ECMO decannulation. This study aimed to determine whether the area-decreasing technique results in reduced arterial blood loss compared with the conventional post-closure technique. Methods and analysis This is a prospective, single-centre, open-label, randomised controlled trial. We plan to recruit 110 participants (aged ≥18 years) from the ECMO Centre of the First Hospital of Lanzhou University, China, all of whom will undergo femoral artery closure using the ProGlide system following V-A ECMO support. Participants will be randomly assigned in a 1:1 ratio to undergo either the conventional post-closure technique or the area-decreasing technique. The primary endpoint is arterial blood loss. Secondary endpoints include immediate technical success rate, arterial suture time, in-hospital mortality, in-hospital lower limb-related complications after decannulation, 30-day mortality and 30-day lower limb-related complications. Safety endpoints include the incidence of complications requiring surgical or interventional management and the rate of amputation. Ethics and dissemination The study protocol was approved by the Ethics Committee of the First Hospital of Lanzhou University (Approval ID: LDYYLL2024-36). Written informed consent was obtained from all participants before data collection. Study findings will be published in a peer-reviewed journal. Trial registration number Chinese Clinical Trial Registry, ChiCTR2400084539

Background: There is a lack of consensus regarding the optimal anticoagulation strategy for continuous renal replacement therapy (CRRT) in patients with hyperlactataemia and a high risk of bleeding. The purpose of this study was to evaluate the safety and efficacy of the commonly used anticoagulation methods for CRRT in these patients. Methods: The present study included patients with hyperlactataemia (⩾2 mmol/L) and a high risk of bleeding who underwent CRRT at Xijing Hospital from 2020 to 2024. Filter lifespan, bleeding complications, blood infusion and adverse effects were recorded. Results: The present study included a total of 53 patients who underwent no anticoagulation (NA)-CRRT, 32 patients who underwent nafamostat mesylate (NM)-CRRT and 47 patients who underwent regional citrate anticoagulation (RCA)-CRRT. The filter lifespan was significantly different among the three groups (NA = 25 h (IQR = 18.4, 34.5), NM = 41 h (IQR = 24.0, 54.3) and RCA = 36 h (IQR = 23.0, 53.5), p < 0.001). The 30-day mortality rate was significantly higher in the NA group ( p = 0.037). Furthermore, the incidence of bleeding complications (43.4%, p = 0.003) and blood transfusions (28.3%, p = 0.047) were higher in the NA group. Conclusion: The utilization of either NM or RCA has the potential to extend the filter lifespan and may be associated with a reduced risk of bleeding. These findings suggest that NM and RCA may be safe and effective for CRRT patients with hyperlactataemia and a high risk of bleeding if careful monitoring and timely adjustment are employed.

Acute kidney injury (AKI) is a syndrome characterized by rapid loss of renal function with a high morbidity and mortality. However, due to the complex pathophysiologic mechanisms of AKI, no specific treatment for this disease is currently available. Animal models have demonstrated the protective effects of exosomes on AKI; however, the underlying mechanisms require further investigation. The present review focuses on the efficacy of exosomes derived from different cell sources, including mesenchymal stem cells, endothelial progenitor cells and tubular epithelial cells, in the treatment of AKI and the associated mechanism. Furthermore, the effects of exosomal contents, including microRNAs, circular RNAs, long non‑coding RNAs, messenger RNAs and proteins, on the repair of renal tubules, protection against renal tubular epithelial cell injury, protection against fibrosis, inhibition of early endoplasmic reticulum stress and mediation of inflammation during AKI are also summarized in the present review.

Background Therapeutic plasma exchange (TPE) is an important blood purification technology and most patients require multiple consecutive TPEs. Regional citrate anticoagulation (RCA) could be used for membrane therapeutic plasma exchange (mTPE). However, there is no research on the metabolic complications of the RCA for patients receiving multiple consecutive mTPEs with fresh frozen plasma (FFP) as a replacement solution. Methods We retrospectively included patients who used RCA for multiple consecutive mTPEs with FFP as a replacement solution in Xijing Hospital from 2020 to 2022. We collected blood gas analysis and electrolyte results before and after mTPE treatment and analysed the anticoagulation effectiveness and metabolic complications of the RCA. Results A total of 33 patients who underwent 131 mTPE sessions were included, and 129 (98.5%) sessions were successfully completed. Severe hypocalcemia (19.1%) and metabolic alkalosis (58.5%) were frequently observed. In single mTPE sessions, there was a significant decrease in ionized calcium levels and significant increases in serum sodium, potassium, pH, bicarbonate, and base excess (BE) levels compared to pretreatment values. When comparing the values after the last treatment to the baseline values in all 33 patients, the serum sodium, pH, bicarbonate, and BE levels increased significantly, while the ionized calcium decreased significantly. The levels of pH, bicarbonate, and BE increased with the number of mTPE sessions, and the cumulative incidence of metabolic alkalosis reached 95.2% after the fifth treatment according to the Kaplan–Meier survival analysis. Conclusion RCA is an effective anticoagulation method for patients undergoing mTPE with FFP as a replacement solution. However, the metabolic complications associated with RCA, especially hypocalcemia and metabolic alkalosis, frequently develop in patients who undergo multiple consecutive mTPEs with FFP.

Background: The optimal anticoagulation regimen for continuous renal replacement therapy (CRRT) in liver failure (LF) patients without increased bleeding risk remains controversial. Therefore, we conducted a monocentric retrospective study to evaluate the efficacy and safety of the regional citrate anticoagulation (RCA) versus low molecular weight heparin (LMWH) anticoagulation for CRRT in LF without increased bleeding risk. Method: According to the anticoagulation strategy for CRRT, patients were divided into the RCA and LMWH-anticoagulation groups. The evaluated endpoints were patient survival, filter lifespan, bleeding, citrate accumulation, and totCa/ionCa ratio. Result: Totally 167 and 164 filters were used in the RCA and LMWH group, respectively. The median filter lifespan was significantly longer in the RCA group (34 h (IQR = 24–54) versus 24 h (IQR = 18–45.5) [95%CI, 24.5–33]; p < 0.001). The 4-week mortality rate was significantly higher in the LMWH-anticoagulation group (71 (57.72%) vs 53 (40.46%); p = 0.006). After adjusted the important parameters in the multivariate COX regression model, the mortality risk was significantly reduced in the RCA group (HR = 0.668 [95%CI, 0.468–0.955]; p = 0.027). In the LMWH group, 30 bleeding episodes (24,19%) were observed, whereas only 7 (5.34%) occurred in the RCA group ( p < 0.001). Two patients (1.5%) in the RCA group occurred citrate accumulation. Conclusions: In LF patients without increased bleeding risk who underwent CRRT, RCA significantly extended the filter lifespan and improved patient survival rate. There was no significant difference in the rate of adverse events between the two groups.

Background: The opinions on the efficacy and safety of no anticoagulation versus regional citrate anticoagulation for continuous KRT (CKRT) were controversial in patients with severe liver failure with a higher bleeding risk. We performed a randomized controlled trial to assess no anticoagulation versus regional citrate anticoagulation for CKRT in these patients. Methods: Adult patients with liver failure with a higher bleeding risk who required CKRT were considered candidates. The included participants were randomized to receive regional citrate anticoagulation or no-anticoagulation CKRT. The primary end point was filter failure. Results: Of the included participants, 44 and 45 were randomized to receive regional citrate anticoagulation and no-anticoagulation CKRT, respectively. The no-anticoagulation group had a significantly higher filter failure rate (25 [56%] versus 12 [27%], P = 0.003), which was confirmed by cumulative incidence function analysis and sensitive analysis including only the first CKRT sessions. In the cumulative incidence function analysis, the cumulative filter failure rates at 24, 48, and 72 hours of the no-anticoagulation and regional citrate anticoagulation groups were 31%, 58%, and 76% and 11%, 23%, and 35%, respectively. Participants in the regional citrate anticoagulation group had significantly higher incidences of Ca²⁺ _tot/Ca²⁺ _ion >2.5 (7% versus 57%, P < 0.001), hypocalcemia (51% versus 82%, P = 0.002), and severe hypocalcemia (13% versus 77%, P < 0.001). However, most (73%) of the increased Ca²⁺ _tot/Ca²⁺ _ion ratios were normalized after the upregulation of the calcium substitution rate. In the regional citrate anticoagulation group, there was no significant additional increase in the systemic citrate concentration after 6 hours. Conclusions: For patients with liver failure with a higher bleeding risk who required CKRT, regional citrate anticoagulation resulted in significantly longer filter lifespan than no anticoagulation. However, regional citrate anticoagulation in patients with liver failure was associated with a significantly higher risk of hypocalcemia, severe hypocalcemia, and Ca²⁺ _tot/Ca²⁺ _ion >2.5. Clinical Trial registry name and registration number: RCA for CRRT in Liver Failure and High Risk Bleeding Patients, NCT03791190.