Bicarbonate- versus lactate-buffered solutions for acute continuous haemodiafiltration or haemofiltration

People with acute kidney injury (AKI) have serious loss of kidney function and are unable to rid wastes from the body in urine. People with AKI need dialysis (haemofiltration) which requires use of buffered solutions (dialysates) to rid waste from their blood. Different dialysates can have various effects on the balance of blood chemistry. Maintaining balanced blood chemistry helps to reduce risks of heart, blood circulation and blood pressure problems. We assessed the benefits and harms of bicarbonate-buffered solutions and lactate-buffered solutions by analysing results from four randomised controlled studies that together involved 171 participants. The evidence was flawed by study design and reporting problems, and the small number of people in the studies. Based on limited evidence from one study (117 participants), we found that people treated with bicarbonate-buffered solutions may experience fewer heart and blood circulation problems and high blood pressure events. The studies did not include enough evidence to make recommendations about the use of these solutions.

Authors' conclusions: 

There were no significant different between bicarbonate- and lactate-buffered solutions for mortality, serum bicarbonate levels, serum creatinine, serum base excess, serum pH, carbon dioxide partial pressure, central venous pressure and serum electrolytes. Patients treated with bicarbonate-buffered solutions may experience fewer cardiovascular events, lower serum lactate levels, higher mean arterial pressure and less hypotensive events. With the exception of mortality, we were not able to assess the main primary outcomes of this review - length of time in ICU, total length of hospital stay and relapse.

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Background: 

Acute kidney injury (AKI) is a severe loss of kidney function that results in patients' inability to appropriately excrete nitrogenous wastes and creatinine. Continuous haemodiafiltration (HDF) or haemofiltration (HF) are commonly used renal replacement therapies for people with AKI. Buffered dialysates and solutions used in HDF or HF have varying effects on acid-base physiology and several electrolytes. The benefits and harms of bicarbonate- versus lactate-buffered HDF or HF solutions for treating patients with AKI remain unclear.

Objectives: 

To assess the benefits and harms of bicarbonate- versus lactate-buffered solutions for HDF or HF for treating people with AKI.

Search strategy: 

We searched the Cochrane Renal Group's Specialised Register to 6 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched the Chinese Biomedical Literature Database.

Selection criteria: 

All randomised controlled trials (RCT) and quasi-RCTs that reported comparisons of bicarbonate-buffered solutions with lactate-buffered solutions for AKI were selected for inclusion irrespective of publication status or language.

Data collection and analysis: 

Two authors independently assessed titles and abstracts, and where necessary the full text of studies, to determine which satisfied our inclusion criteria. Data were extracted by two authors who independently assessed studies for eligibility and quality using a standardised data extraction form. Methodological quality was assessed using the Cochrane risk of bias tool. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

Main results: 

We identified four studies (171 patients) that met our inclusion criteria. Overall, study quality was suboptimal. There were significant reporting omissions related to methodological issues and potential harms. Outcome measures were not defined or reported adequately. The studies were small and lacked follow-up phases.

Serum lactate levels were significantly lower in patients treated with bicarbonate-buffered solutions (4 studies, 171 participants: MD -1.09 mmol/L, 95% CI -1.30 to -0.87; I2 = 0%). There were no differences in mortality (3 studies, 163 participants: RR 0.76, 95% CI 0.50 to 1.15; I2 = 0%); serum bicarbonate levels (3 studies, 163 participants: MD 0.27 mmol/L, 95% CI -1.45 to 1.99; I2 = 78%), serum creatinine (2 studies, 137 participants: MD -22.81 µmol/L, 95% CI -129.61 to 83.99; I2 = 73%), serum base excess (3 studies, 145 participants: MD 0.80, 95% CI -0.91 to 2.50; I2 = 38%), serum pH (4 studies, 171 participants: MD 0.01, 95% CI -0.02 to 0.03; I2 = 70%) or carbon dioxide partial pressure (3 studies, 151 participants: MD -1.04, 95% CI -3.84 to 1.76; I2 = 83%). A single study reported fewer cardiovascular events (RR 0.39, 95% CI 0.20 to 0.79), higher mean arterial pressure (10.25 mm Hg, 95% CI 6.68 to 13.82) and less hypotensive events (RR 0.44, 95% CI 0.26 to 0.75) in patients receiving bicarbonate-buffered solutions. One study reported no significant difference in central venous pressure (MD 2.00 cm H2O, 95% CI -0.7 to, 4.77). Total length of hospital and ICU stay and relapse were not reported by any of the included studies.

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