Citrate as a safe and effective alternative to heparin for catheter locking: a systematic review and meta-analysis of randomized controlled trials

Hua Luo ^1* Binbin Lai ¹ Weixing Huang ¹ Hui Yu ¹ Tingting Chen ¹ Yimen Gao ¹ Wei Wang ²

• ¹ Zhejiang Taizhou Hospital, Taizhou, China
• ² First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

Background: Consensus on the use of citrate versus heparin for catheter locking remains elusive, with ongoing controversy. This meta-analysis investigates the efficacy and safety of citrate lock solutions compared to heparin lock solutions in preventing catheter-related complications.The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers conducted literature searches based on preferred reporting items from systematic reviews and meta-analyses. PubMed, EMBASE, Medline, and the Cochrane Library were searched for studies comparing citrate and heparin in patients with catheter. Catheter-related bloodstream infection (CRBSI), catheter-related infection (CRI), exit-site infection (ESI), and adverse events were analyzed.The meta-analysis included 189 randomized controlled trials (RCTs), encompassing 258,722251,388 catheter-days, with 130,904133,472 in the citrate group and 120,484125,250 in the heparin group. Citrate lock solutions significantly reduced the incidence of CRBSI compared to heparin (RR: 0.49, 95% CI: 0.32 to 0.75), particularly when combined with antibiotics or used at low concentrations. No significant differences were observed between the groups for CRI, ESI, catheter dysfunction, or local bleeding. Subgroup and sensitivity analyses addressed heterogeneity, confirming the robustness of the primary findings. The results demonstrated that citrate, when combined with antibiotics, significantly reduced the incidence of CRBSI compared to heparin lock solutions. However, citrate alone did not show a significant difference in preventing CRBSI and CRI compared to heparin but did show 4 superiority in reducing ESI. There were no significant differences between citrate and heparin in terms of catheter malfunction and local bleeding rates.Conclusions: Citrate lock solutions effectively prevent catheter-related complications without increasing systemic coagulation dysfunction or bleeding risk. Citrate lock solutions are a safe and effective alternative to heparin, especially when combined with antibiotics.Citrate lock solutions offer effective anticoagulation without causing systemic coagulation dysfunction or increasing bleeding risk, owing to their ability to chelate calcium ions and their inherent antibacterial properties. The findings suggest that citrate, even without antibiotics, is as effective as heparin in preventing CRBSI and CRI, making it a safer and more effective option for catheter locks.