Although technology has significantly evolved and current cartridges for hemoperfusion can be safely used with many potential applications, current evidence is insufficient to recommend routine use in all patients presenting indications. Further research is needed, including a better refinement of the indications for extracorporeal blood purification techniques and improved selectivity of target solutes, especially once immunophenotypes of septic patients can be specifically identified and monitored. |
Pathophysiology of sepsis
The blood purification hypothesis
The rationale for hemoperfusion
Technical concepts of adsorption
Sorbent polymer | Commercial name (manufacturer) | Amount of sorbent | Coating |
---|---|---|---|
Norit charcoal | Adsorba (Gambro) | 100–300 g | Cellulose acetate |
Polymyxin B | Toraymyxin (Estor) | – | – |
Spherical charcoal | Hemosorba (Asahi) | 170 g | Polyhema |
Polystyrene divinyl benzene | HA 130/230/330 (Jafron) | – | None |
Polystyrene divinyl benzene | Cytosorb (Aferetica) | 300 g | None |
Ultra-high molecular weight polyethylene beads with end-point-attached heparin | Seraph-100 (ExThera Medical) | – | – |
Available sorbents
Charcoal and resins
Polymyxin B hemoperfusion
First author, year of publication, acronym/device | Population/Sample size | Trial design/Intervention | Primary end point/Time of assessment | Results |
---|---|---|---|---|
Cruz, 2009, EUPHAS (PMX-DH) | Post-operative abdominal sepsis, multicenter/ n = 64 | Parallel group, 1:1 randomized, open label/2 sessions of 2 h of PMX HP | Change in MAP and vasopressor support at 72 h | MAP increased in HP group. HP 76 mmHg (95% CI 72–80 mmHg) to 84 mmHg (95% CI 80–88 mmHg), p = 0.001 vs control 74 mmHg (95% CI 70–78 mmHg) to 77 mmHg (95% CI 72–82 mmHg), p = 0.37 Inotropic score decreased in HP group. HP 29.9 (95% CI 20.4–39.4) to 6.8 (95% CI 2.9–10.7), p < 0.001 vs control 28.6 (95% CI 16.6–40.7) to 22.4 (95% CI 9.3–35.5), p = 0.14 |
Payen, 2015, ABDO-MIX (PMX-DH) | Post-operative abdominal sepsis, multicenter/n = 243 | Parallel group, 1:1 randomized, open label/2 sessions of 2 h of PMX HP | Mortality at 28 days | Neutral. HP group vs control group mortality, 27.7 vs 19.5%, respectively (OR 1.58, 95% CI 0.85–2.93), p = 0.14 |
Dellinger, 2018, EUPHRATES (PMX-DH) | Septic shock and endotoxin activity assay ≥ 0.60, multicenter/n = 450 | Parallel group, 1:1 randomized, masked to investigator/2 sessions of 2 h of PMX HP | Mortality at 28 days | Neutral. HP group vs control (sham) group mortality, 37.7 vs 34.5%, respectively (RR 1.09, 95% CI 0.85–1.39), p = 0.49 |
Klein, 2018, EUPHRATES post hoc analysis (PMX-DH) | Septic shock and endotoxin activity assay ≥ 0.60–0.89, multicenter/n = 194 | Parallel group, 1:1 randomized, masked to investigator/2 sessions of 2 h of PMX HP | Mortality at 28 days | Reduced mortality in HP group. HP group vs control (sham) group mortality, 26.1 vs 36.8%, respectively (OR 0.52, 95% CI 0.27–0.99), p = 0.047 |
Schädler, 2017 (Cytosorb) | Mechanically ventilated septic patients, multicenter/n = 97 | Parallel group, 1:1 randomized, open label/up to 7 sessions of 6 h/day of copolymer HP with CytoSorb | Normalized interleukin 6 concentration at day 7 | Neutral. Log-transformed interleukin 6 concentration equivalent in HP group vs control group, (95% CI for the concentration was not informed), p = 0.153 |
Garcia, 2021 (Cytosorb) | Refractory septic shock patients with interleukin 6 ≥ 1000 ng/L, single-center/n = 48 (prospective)n = 48 (historical) | Prospective cohort and comparative historic cohort, 1:1 matched/3 sessions of 24 h of CRRT plus copolymer HP with CytoSorb | Change in interleukin 6 and vasopressor requirement at 72 h; mortality at 30 days | Neutral for interleukin 6, which decreased irrespectively of HP, p = 0.254 Neutral for vasopressor requirement, which decrease irrespectively of HP, p = 0.555 Increased mortality in HP group. HP vs historic control group, 67% vs 42%, respectively (competing risks hazard ratio 1.82, 95% CI 1.03–3.2), p = 0.038 |
Supady, 2021, CYCOV (Cytosorb) | COVID-19 pneumonia patients requiring ECMO, single-center/n = 34 | Parallel group, 1:1 randomized, open label/3 sessions of 24 h/day of copolymer HP with CytoSorb integrated to the ECMO circuit | Interleukin 6 concentration at 72 h | Neutral. Interleukin 6 concentration in HP group 98.6 pg/mL (IQR 71–192.8 pg/ mL) vs control group 112 pg/mL (IQR 48.7–198.5 pg/mL), p = 0.54 |
Stockmann, 2022 (Cytosorb) | COVID-19 patients with vasoplegic shock, single-center/n = 49 | Parallel group, 1:1 randomized, open label/3 to 7 sessions of 24 h of CRRT plus copolymer HP with CytoSorb | Time until resolution of vasoplegic shock (i.e., more than 8 h without vasopressors | Neutral. Time until resolution of vasoplegic shock in HP group vs control group, 5 days (IQR 4–5 days) vs 4 days (IQR 3–5 days), respectively, HR 1.23 (95% CI 0.56–2.71), p = 0.63 |
Diab, 2022, REMOVE (Cytosorb) | Cardiac surgery patients with infective endocarditis, multicenter/n = 282 | Parallel group, 1:1 randomized, open label/1 session of copolymer HP with CytoSorb during cardiopulmonary bypass | Change in SOFA score assessed 24 h after the surgery up to the 9th postoperative day | Neutral. SOFA score variation in HP group vs control group, 1.79 ± 3.75 vs 1.93 ± 3.53, respectively (95% CI -1.30 to 0.83), p = 0.666 |
Supady, 2022, CYTER (Cytosorb) | Post-cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation with ECMO/n = 26 | Parallel group, 1:1 randomized, open label/3 sessions of 24 h/day of copolymer HP with CytoSorb integrated to the ECMO circuit | Interleukin 6 concentration at 72 h | Neutral. Median interleukin 6 reduction in HP group from 408 pg/mL (IQR 93.4–906.5) to 324 pg/mL (IQR 134.3–4617.3) vs increment in control group from 133 pg/mL (IQR 56.2–528.5) to 241 pg/mL (IQR 132.8–718), p = 0.48 |