Efficacy and safety of nafamostat mesylate versus heparin anticoagulation in adult kidney disease patients using continuous renal replacement therapy: a systematic review and meta-analysis

Background Anticoagulation is essential during continuous renal replacement therapy (CRRT) for acute kidney injury to maintain circuit patency and balance bleeding risks. Objective Systematically compare the anticoagulant efficacy and safety of nafamostat mesylate (NM) versus heparin in CRRT. Methods We searched China National Knowledge Infrastructure, Wanfang Database, China Biology Medicine, PubMed, Embase, Cochrane Library, and Web of Science up to June 30, 2025 for randomized or non-randomized controlled trials. A meta-analysis was performed using RevMan version 5.4 software. Results Seven retrospective cohort studies comprising were included. No significant differences between the two groups regarding filter lifespan [MD = -1.05; 95% CI (-5.92, 3.83); P = 0.67] and anticoagulation efficacy [OR = 2.64; 95% CI (0.41, 17.11); P = 0.31] were shown. No difference in the risk of bleeding events was shown [OR = 0.57; 95% CI (90.27, 1.21); P = 0.14]. The length of hospital stay in the NM group was significantly shortened [MD = –3.43; 95% CI (–5.53 to –1.33); P = 0.001]. NM showed significantly greater reduction in thrombin time (TT) compared to heparin [MD = –3.44; 95% CI (–5.33, –1.56); P = 0.0003), while no significant differences were observed in activated partial thromboplastin time (APTT) [MD = –5.35; 95% CI (–16.41, 5.72); P = 0.34) or international normalized ratio (INR) [MD = –0.46; 95% CI (–1.12, 0.20); P = 0.17]. Conclusion NM demonstrates similar filter lifespan and bleeding safety to heparin in CRRT. NM may shorten hospital stay and differentially affects coagulation indicators, supporting its use in individualized anticoagulation. But because of poor evidence, the conclusions must be interpreted with caution. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251077749.