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Background: Coronavirus disease-19 (COVID-19) ranges from asymptomatic infection to severe cases requiring admission to the intensive care unit. Together with supportive therapies (ventilation in particular), the suppression of the pro-inflammatory state has been a hypothesized target. Pharmacological therapies with corticosteroids and interleukin-6 (IL-6) receptor antagonists have reduced mortality. The use of extracorporeal cytokine removal, also known as hemoperfusion (HP), could be a promising non-pharmacological approach to decrease the pro-inflammatory state in COVID-19., Methods: We conducted a systematic review of PubMed and EMBASE databases in order to summarize the evidence regarding HP therapy in COVID-19. We included original studies and case series enrolling at least five patients., Results: We included 11 articles and describe the characteristics of the populations studied from both clinical and biological perspectives. The methodological quality of the included studies was generally low. Only two studies had a control group, one of which included 101 patients in total. The remaining studies had a range between 10 and 50 patients included. There was large variability in the HP techniques implemented and in clinical and biological outcomes reported. Most studies described decreasing levels of IL-6 after HP treatment., Conclusion: Our review does not support strong conclusions regarding the role of HP in COVID-19. Considering the very low level of clinical evidence detected, starting HP therapies in COVID-19 patients does not seem supported outside of clinical trials. Prospective randomized data are needed., (© 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Objective: The objective of this study was to conduct a meta-analysis and trial sequential analysis (TSA) of published randomized controlled trials (RCTs) to determine whether mortality benefit exists for extracorporeal blood purification techniques in sepsis., Data Sources: A systematic search on MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for RCTs was performed., Study Selection: RCTs investigating the effect of extracorporeal blood purification device use on mortality among critically ill septic patients were selected., Data Extraction: Mortality was assessed using Mantel-Haenszel models, and I2 was used for heterogeneity. Data are presented as odds ratios (OR); 95% confidence intervals (CIs); p values; I2. Using the control event mortality proportion, we performed a TSA and calculated the required information size using an anticipated intervention effect of a 14% relative reduction in mortality., Data Synthesis: Thirty-nine RCTs were identified, with 2,729 patients. Fourteen studies used hemofiltration (n = 789), 17 used endotoxin adsorption devices (n = 1,363), 3 used nonspecific adsorption (n = 110), 2 were cytokine removal devices (n = 117), 2 used coupled plasma filtration adsorption (CPFA) (n = 207), 2 combined hemofiltration and perfusion (n = 40), and 1 used plasma exchange (n = 106). On conventional meta-analysis, hemofiltration (OR 0.56 [0.40-0.79]; p < 0.001; I2 = 0%), endotoxin removal devices (OR 0.40 [0.23-0.67], p < 0.001; I2 = 71%), and nonspecific adsorption devices (OR 0.32 [0.13-0.82]; p = 0.02; I2 = 23%) were associated with mortality benefit, but not cytokine removal (OR 0.99 [0.07-13.42], p = 0.99; I2 = 64%), CPFA (OR 0.50 [0.10-2.47]; p = 0.40; I2 = 64%), or combined hemofiltration and adsorption (OR 0.71 [0.13-3.79]; p = 0.69; I2 = 0%). TSA however revealed that based on the number of existing patients recruited for RCTs, neither hemofiltration (TSA-adjusted CI 0.29-1.10), endotoxin removal devices (CI 0.05-3.40), nor nonspecific adsorption devices (CI 0.01-14.31) were associated with mortality benefit., Conclusion: There are inadequate data at present to conclude that the use of extracorporeal blood purification techniques in sepsis is beneficial. Further adequately powered RCTs are required to confirm any potential mortality benefit, which may be most evident in patients at greatest risk of death., (© 2020 S. Karger AG, Basel.)

BACKGROUND This study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios. MATERIAL AND METHODS Data from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease - sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria. RESULTS During the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015). CONCLUSIONS MARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

Endotoxin is recognized as a major trigger of the immune response leading to pro- and anti-inflammatory cytokine release, activation of the coagulation cascade, vasoplegic shock, and multiple organ dysfunction syndrome. A beneficial effect could be achieved through extracorporeal adsorption of circulating endotoxins in the blood as adjunctive treatment for unresponsive endotoxic shock. However, the precise clinical indication for its initiation is widely debated in the literature. Similar to the source control, microbiological cultures and antibiotics administration, endotoxin activity assay evaluation at regular intervals, and the targeted use of PMX-B hemoperfusion could be lifesaving and adequate within the golden hour for the diagnosis and treatment of endotoxic shock., (© 2019 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals, Inc.)

Background: Residual renal function (RRF) is an important determinant of mortality and morbidity in patients undergoing hemodialysis. Different dialysis types may have different effects on RRF. We therefore conducted this meta-analysis to examine the RRF protective effect of different dialysis types for hemodialysis patients., Methods: A systematic search was performed on PubMed, EMbase, Web of Science, Chinese Biomedical Literature Database, Wanfang database, and China National Knowledge Infrastructure for randomized controlled trials and cohort studies. Dialysis types included low-flux hemodialysis (LFHD), high-flux hemodialysis (HFHD), hemodiafiltration (HDF), and hemodialysis and hemoperfusion (HD+HP). The mean of endogenous creatinine clearance rate (CCR) and urea clearance rate (Curea), or urine volume was used to estimate RRF [95% confidence interval (95% CI), 6.05-16.80]., Results: There were 12 articles involving 1224 patients, including 11 random controlled trials and 1 cohort study. Meta-analysis showed that the RRF protective effect of HFHD [mean difference (MD) = 1.48, 95% CI (2.11 to 0.86), P < .01] and HD+HP [MD = 0.41, 95% CI (0.69 to 0.12), P = .005] was better than that of LFHD, and the RRF decline rate was the lowest in HFHD group [MD = 0.13, 95% CI (0.17 to 0.09), P < .01]. Descriptive analysis showed that HDF could better protect RRF when compared with LFHD. However, there was no consistency among other interventions when removing LFHD due to limited data., Conclusion: For patients undergoing maintenance hemodialysis, the HFHD, HD+HP and HDF may better protect RRF, compared with LFHD.

Introduction: Haemodialysis (HD) is the cornerstone treatment for patients with end-stage renal disease (ESRD). However, highly protein bound or large molecular weight uremic toxins such as phenolic and indolic compounds and homocysteine, which are associated with adverse outcomes such as cardiovascular disease of patients with ESRD, are difficult to remove via HD but can be effectively eliminates by haemoperfusion (HP). The proposed trial (referred to as HD/HP vs HD below) is a randomised, open-label, multicentre trial comparing HD plus HP versus HD alone in adult patients with ESRD. The primary endpoint measure is all-cause mortality., Methods and Analysis: We plan to enrol 1364 maintenance HD patients from 11 medical centres in Shanghai. Participants will be randomised to receive HD plus HP or HD alone at a 1:1 ratio after 1-month run-in period. In both arms, patients will receive low-flux HD at a frequency of two times a week and haemodiafiltration at a frequency of once a week. In the intervention group, subjects also received HP once every 2 weeks. Follow-up is scheduled at 3, 6, 12, 18 and 24 months after randomisation, and will consist the following: routine physical examinations, standard lab panels (blood routine, liver/residual kidney functions, tests of the coagulation system, etc), dialysis adequacy (standard Kt/V), chest X-ray, ECG, echocardiography, heart function rating. Adverse events will be assessed according to the international conference on harmonisation guidelines. The primary outcome is 24-month all-cause mortality. Secondary outcomes will include cardiovascular-related mortality, the occurrence of major cardiovascular events and the quality of life., Ethics and Dissemination: The study protocol has been approved by the Ethical Committees of all 11 participating centres. Clinical Research Unit of Xin Hua Hospital will oversee the study. The results will be presented at national and international academic meetings, and submitted to peer-reviewed journals for publications., Trial Registration Number: NCT03227770; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Mortality in patients with paraquat (PQ) poisoning is related to plasma PQ levels. Concentrations lower than 5,000 ng/mL are considered critical but curable. This study assessed the effects of hemoperfusion (HP) and continuous renal replacement therapy (CRRT) on the survival of PQ-poisoned patients with plasma PQ levels below 5,000ng/mL. We analyzed the records of 164 patients with PQ poisoning who were treated at the First Affiliated Hospital of Wenzhou Medical University in China between January 2011 and May 2015. We divided these patients into six sub-groups based on baseline plasma PQ levels and treatment, compared their clinical characteristics, and analyzed their survival rates. Patient sub-groups did not differ in terms of age, sex, time between poisoning and hospital admission, or time to first gavage. Biochemical indicators improved over time in all sub-groups following treatment, and the combined HP and CRRT treatment yielded better results than HP or CRRT alone. Fatality rates in the three treatment sub-groups did not differ among patients with baseline plasma PQ levels of 50-1,000 ng/mL, but in patients with 1,000-5,000 ng/mL levels, the mortality rate was 59.2% (HP treatment group), 48% (CRRT treatment group), and 37.9% (combined treatment group). Mortality rates were higher 10-30 days after hospitalization than in the first 10 days after admission. In the early stages of PQ poisoning, CRRT is effective in reducing patient fatality rates, particularly when combined with HP. Our data could be useful in increasing survival in acute PQ poisoning patients.

Background: Direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP) therapy has been approved for sepsis-associated acute respiratory distress syndrome, but its efficacy for other rapidly progressive interstitial pneumonias (RPIPs) is unclear. The purpose of this study was to examine the efficacy of PMX-DHP therapy for acute respiratory failure in patients with RPIPs, when compared with a historical control receiving conventional treatment without PMX-DHP., Methods: This study comprised 77 patients with RPIPs in our institute between January 2002 and December 2015. The initial 36 patients between January 2002 and March 2007 were treated without PMX-DHP (historical control group), and the following 41 patients between April 2007 and December 2015 were treated with PMX-DHP (PMX-DHP group) once daily for two successive days concurrently with corticosteroids and/or immunosuppressive agents. The 90-day mortality and clinical factors were compared between the groups. Cox proportional hazards models were constructed to analyze 90-day mortality and identify predictors., Results: The 90-day mortality rate was significantly lower in the PMX-DHP group than in the controls (41.5% versus 66.7%, p = 0.019). PMX-DHP therapy was significantly associated with mortality (hazard ratio 0.505; 95% confidence interval, 0.270-0.904; p = 0.032). There were significant differences in the serial changes in the PaO 2 /FiO 2 ratio, SOFA score, and blood neutrophil counts from days 0-5 after PMX-DHP between the survivor and non-survivor groups ( p = 0.015, p < 0.001, p = 0.035, respectively). The improved PaO 2 /FiO 2 ratio on day 3 significantly correlated with the change in blood neutrophil counts (r s = -0.431, p = 0.006)., Conclusions: PMX-DHP therapy may be effective in RPIPs patients accompanied by acute respiratory failure and is expected to reduce mortality rates.

Background/aims: We assessed the survival benefit of polymyxin B hemoperfusion (PMX) in septic shock patients starting continuous renal replacement therapy (CRRT), who are known to have an increased rate of mortality., Methods: Adult patients in the Japanese diagnosis procedure combination database satisfying the following criteria were enrolled: hospitalized in 2007-2012; diagnosed as having sepsis; required noradrenaline and/or dopamine; and started CRRT in intensive care unit. Propensity scores for receiving PMX were created from patient and hospital characteristics., Results: Of 3,759 eligible patients, 1,068 received PMX. Propensity-score matching produced a matched cohort of 978 pairs. The 28-day mortality was 40.2% (393/978) in the PMX group and 46.8% (458/978) in the control group (p = 0.003). Logistic regression analysis revealed a significant association between the use of PMX and decreased 28-day mortality (adjusted OR 0.75; 95% CI 0.62-0.91)., Conclusion: This large retrospective study suggests that septic shock patients starting CRRT may benefit from PMX., (© 2016 S. Karger AG, Basel.)

Objective Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) are fatal episodes of acute respiratory worsening of unknown etiology. Previous studies on acute respiratory distress syndrome have shown that direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) can have a beneficial effect on the respiratory status. This retrospective study investigated the prognosis and survival outcome of patients with AE-IPF who underwent PMX-DHP. Methods We examined the records of 50 patients with AE-IPF treated in our hospital. All patients received corticosteroid pulse therapy. We compared the disease outcome between 27 patients who underwent PMX-DHP (PMX group) and 23 patients who did not (non-PMX group). The independent predictors of survival were determined using Cox proportional hazards analyses. Results A multivariate analysis of all patients revealed that PMX-DHP therapy was a significant predictor of survival (HR=0.442, 95% CI 0.223-0.873; p=0.019). The 12-month survival rate was significantly higher in the PMX group than in the non-PMX group (41.7% vs. 9.8%; p=0.040). According to a subanalysis of the PMX group, the time from AE-IPF onset to PMX-DHP was a significant predictor of survival (HR=1.080, 95% CI 1.001-1.166; p=0.049). Conclusion PMX-DHP improved the prognosis of AE-IPF. The time from AE-IPF onset to PMX-DHP may therefore be informative for predicting the patient outcome.

The aim of the present study was to investigate the impact of three different blood purification methods, hemoperfusion (HP), continuous blood purification (CBP), and on-line high-volume hemodiafiltration (OL-HDF), on the survival rate of patients with acute severe organophosphorus pesticide poisoning (ASOPP), as well as on major pro-inflammatory (interleukin [IL]-1, IL-6, tumor necrosis factor-α [TNF-α]) and anti-inflammatory (IL-10) cytokines in the serum. Eighty-one ASOPP patients were randomly divided into three groups: HP (N = 23), HP + CBP (N = 26), HP + OL-HD (N = 32). Serum IL-1, IL-6, TNF-α, and IL-10 levels were assessed by ELISA before treatment and at 24 and 48 h post-treatment and survival rates were determined. Patient survival rate was significantly higher in OL-HDF and CBP treated patients compared with HP group (P < 0.05). A significantly greater clearance effect in serum IL-1, IL-6, and TNF-α levels at 24 and 48 h post-treatment was observed in CBP and OL-HDF groups compared with the HP group (P < 0.05). The levels of serum anti-inflammatory cytokine IL-10 increased significantly in CBP and OL-HDF groups compared with the HP group (P < 0.05 at 48 h post-treatment). In addition, OL-HDF treatment achieved similar changes in serum TNF-α, IL-1, IL-6 and IL-10 levels as CBP (P > 0.05). Compared with the HP method, CBP or OL-HDF combined with HP can rapidly clear inflammatory cytokines, reduce systemic inflammatory response syndrome, and improve the survival of ASOPP patients. Compared with CBP, OL-HDF is an economical and effective method to treat ASOPP with less technical difficulty and more suitability for rural areas and primary hospitals., (© 2014 The Authors. Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis.)

Objectives: To examine the effect of postoperative polymyxin B hemoperfusion on mortality in patients with abdominal septic shock triggered by lower gastrointestinal tract perforation, identifying subpopulations of patients who may benefit from this treatment., Design: Propensity-matched analysis., Setting: We used a nationwide inpatient database in Japan., Patients: We included patients who are 18 years old or older hospitalized during a period of 34 months between July 2007 and October 2011, who had open abdominal surgery on the day of admission (day 0) for perforation of lower gastrointestinal tract, and who required noradrenaline and/or dopamine. We excluded patients who died on day 0 or 1 and patients starting polymyxin B hemoperfusion on day 2 or later., Measurements and Main Results: The main outcome was 28-day mortality. Of 2,925 eligible patients, 642 received one or two polymyxin B hemoperfusion sessions, starting the first one on day 0 or 1. Propensity score matching created a matched cohort of 1,180 patients (590 pairs with and without polymyxin B hemoperfusion). The 28-day mortality was 17.1% (101 of 590) in the polymyxin B hemoperfusion group and 16.3% (96 of 590) in the control group (p = 0.696). Subgroup analyses by number of polymyxin B hemoperfusion sessions (one or two), timing of polymyxin B hemoperfusion initiation (day 0 or 1), the use of noradrenaline, and number of dysfunctional organs (one to six) did not show any significant difference in 28-day mortality between the groups. Multiple logistic did not show a significant association between the use of polymyxin B hemoperfusion and 28-day mortality (adjusted odds ratio, 1.10; 95% CI, 0.80-1.51; p = 0.569). Age, end-stage renal disease requiring maintenance hemodialysis, the use of noradrenaline, and number of dysfunctional organs were positively associated with 28-day mortality., Conclusions: In this retrospective study, postoperative polymyxin B hemoperfusion did not show any survival benefit for the overall study population or any of the studied subgroups of patients with abdominal septic shock. A large multicentered prospective randomized trial is warranted to identify the true role of polymyxin B hemoperfusion in sepsis caused by Gram-negative bacteria.

Background: Vasopressin and direct hemoperfusion with an immobilized polymyxin B column (PMX) have emerged recently as treatments for septic shock. This study assessed the impact of these two treatments on the survival of patients with septic shock., Methods: A retrospective, matched cohort study was performed to compare patients who had septic shock and were treated with PMX or vasopressin. The primary endpoint was the 90-day mortality rate. 30 patients receiving PMX were matched to 30 treated with vasopressin., Results: The 90-day survival rate was significantly higher in the vasopressin group than the PMX group (83% vs. 53%; p = 0.008). In the PMX group, the subgroup with gastrointestinal surgery had a significantly higher survival rate than the subgroup without surgery (76.9% vs. 52.9%; p = 0.01). Cox multivariate analysis showed that vasopressin therapy (versus PMX; HR = 0.27; p < 0.01). The estimated hazard ratio for the SOFA score was 1.44 (p < 0.01), and total pressor dosage an baseline was 1.26 (p = 0.01)., Conclusion: We found a significant reduction of the mortality rate in septic shock patients who received vasopressin compared with PMX. In the PMX group, the subgroup with gastrointestinal surgery had a significantly higher survival rate than the subgroup without such surgery.

Objective: To investigate whether the combination of maintenance hemodialysis (MHD) with hemoperfusion (HP) could improve the clearance rate of middle and large molecule uremic toxins so as to improve the quality of life of MHD patients and reduce their mortality rate., Methods: This study was a prospective, randomized, controlled clinical trial. 100 MHD patients were selected and then randomly divided into two groups after four weeks of run-in period. Group 1 received HD alone 2 times a week and the combined treatment of HD with HP (HD+HP) once a week, whereas Group 2 was given HD alone 3 times a week. This study was followed up for a mean of 2 years. The primary outcome was the death of patients. Secondary end points included normal clinical data, leptin, high sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), ß(2) microglobulin (ß(2)-MG), immunoreactive parathyroid hormone (iPTH), tumor necrosis factor-α (TNF-α) and the index of dimensions of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Chinese Edition )., Results: At the end of the two-year observation, the serum concentration of leptin, hsCRP, iPTH, IL-6, ß(2)-MG and TNF-α, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), cardiothoracic ratio, left ventricular mass index (LVMI), the EPO doses and the types of antihypertensive drugs used were lower with Group 1 than with Group 2 (p<0.05); Group 1 had higher hemoglobin (Hb), ejection fraction (EF), and body mass index (BMI) (p<0.05). No statistical difference between the two groups was observed in terms of serum albumin, serum iron (SI), total iron binding capacity (TIBC), cardiac output (CO), Kt/V, early/atrial mitral inflow velocities (E/A) (p>0.05). Besides, the SF-36 indicated that the total score of overall dimentions of Group 1 was higher than Group 2 (p<0.05) and the quality of life of Group 1 was evidently better than Group 2. The Kaplan-Meier Survival Curves for the 2-year observation period showed that patients in Group 1 had obvious survival advantage while Log-rank test results showed p<0.05. No serious adverse incidents occurred during the HD+HP treatment., Conclusions: HD+HP was superior to HD in regularly eliminating middle and large molecule uremic toxins accumulated in the body. These findings suggest a potential role for HD+HP in the treatment to improve the quality of life and survival rate of MHD patients.

Purpose: Endotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE., Methods: From November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006., Results: PMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups., Conclusion: Intraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE., (© The Japanese Association for Thoracic Surgery 2011)

Extracorporeal removal techniques are effective methods for toxin removal from the body. To define the safety and clinical outcomes of hemoperfusion, we evaluated retrospectively clinical outcomes of hemoperfusion over a 3-year period in our clinical center. From January 2006 to December 2008, we analyzed 803 patients. Mortality, catheter-related bleeding, systemic bleeding, hypocalcemia, and thrombocytopenia were investigated. Medical drugs (n = 54) and pesticide toxins (n = 749) were represented. Pesticides included herbicides (n = 598), insecticides (n = 130), mixed herbicides and insecticides (n = 4), and unknown pesticides (n = 17). Among those with herbicide poisoning, 493 cases were caused by paraquat, and among those affected by insecticides, 67 cases were caused by organophosphate insecticides. After hemoperfusion, systemic bleeding complications were observed in 26 cases (3.0%). Systemic bleeding was a greater mortality risk factor than nonsystemic bleeding (OR 2.779, 95% CI 1.07-7.23). Hypocalcemia was observed in 69.1% and thrombocytopenia in 31.1%. Excess mortality was 44.4%. In hemoperfusion cases, systemic bleeding is a major factor to predict adverse outcome., (Copyright © 2010 S. Karger AG, Basel.)

Sepsis involves a complex interaction between bacterial toxins and the host immune system. Endotoxin, a component of the outer membrane of Gram-negative bacteria, is involved in the pathogenesis of sepsis producing proinflammatory cytokines and activating the complement system, and is thus an ideal potential therapeutic target. Direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-F) has been shown to bind and neutralize endotoxin in both in vitro and in vivo studies. Therefore, this extracorporeal therapy with PMX-F can potentially interrupt the biological cascade of sepsis. A systematic review of the published literature found positive effects of PMX-F on blood pressure and dopamine/dobutamine use, the PaO(2)/FiO(2) ratio, endotoxin removal, and mortality. It should be noted, however, that many of the analyzed studies were of suboptimal quality, which may then exaggerate the magnitude of these effects. Since this meta-analysis, other studies have been published including a multicenter randomized controlled trial on abdominal septic shock. In this study, PMX-F, when added to conventional therapy, significantly improved hemodynamics and organ dysfunction, and reduced 28-day mortality in this targeted population. There is clear biological rationale for endotoxin removal in the clinical management of severe sepsis and septic shock. The current literature seems to provide some support for this premise, and provides the basis for further rigorous study., (Copyright 2010 S. Karger AG, Basel.)

The pathophysiological consequence associated with cardiopulmonary bypass (CPB) has generated a movement away from this technology in the treatment of heart disease. The negative outcomes are multifactorial in origin and may be associated both with the conduct of CPB and the instrumentation of extracorporeal flow. The purpose of this study was twofold. First, to develop a bedside patient risk assessment to aid in the development of a perfusion care plan. Second, to identify the controllable variables used during CPB that contribute to overall morbidity. Controllable perfusion-related variables that were positively linked to improved patient outcomes were identified from randomized, peer-reviewed human studies. Such variables as hematocrit, mean arterial pressure, thermic perfusion, blood lactate, colloid osmotic pressure, pulsatile perfusion, acid base homeostasis, oxygenation, and coated circuitry were included. Patient risk assessment was developed using the Society of Thoracic Surgeon database, where 61 variables affecting postoperative morbidity were identified. These variables were used to develop a bedside tool, Mortality Assessment Perfusion Score (MAPS), to guide the perfusion patient care plan. The MAPS generates a specific value that may predict patient morbidity and mortality based on past mortalities. In conclusion, the improvement in patient outcome may be associated with both the change in conduct of CPB and the quantitative assessment of patient risk stratification and a patient treatment algorithm.

Objective: To determine the comparative efficacy of hemoperfusion and hemodialysis for severe theophylline toxicity in concurrent case series., Methods: A 10-year, prospective, observational study was performed of consecutive patients referred to a regional poison control center with severe theophylline intoxication in whom either hemodialysis or hemoperfusion was used. The primary outcomes were 1) incidence of major theophylline toxicity (convulsions or life-threatening cardiac dysrhythmias) during or after each procedure, 2) calculated theophylline clearance, and 3) procedure-related complications., Results: Over the study period, 56 patients underwent hemodialysis or hemoperfusion as treatment of severe theophylline intoxication. Overall mean age was 40.5 +/- 22.9 years. Mean peak serum theophylline concentration was 103.3 +/- 39.1 micrograms/mL (range 36 to 245 micrograms/mL). Thirty patients (54%) were victims of acute theophylline intoxication, while 18 (32%) had chronic overmedication and 8 (14%) had acute-on-therapeutic intoxication. Thirty-nine patients (70%) underwent hemodialysis, while 17 (30%) underwent hemoperfusion. There were no significant intergroup differences in age (39.4 vs 43.0 yr), peak serum theophylline concentration (99.5 vs 112.1 micrograms/mL), time to procedure (8.4 vs 6.3 hr), or duration of procedure (4.1 vs 3.7 hr). Thirty-three percent of the patients undergoing hemodialysis had major toxicity during or after the procedure, compared with 18% of those who received hemoperfusion (p = NS). Post-procedure serum theophylline concentrations were 26.9 vs 30.4 micrograms/mL, corresponding to drug clearance rates of 185.1 and 294.8 mL/kg/hr (p = 0.03). Procedural complications occurred in 3 patients who received hemoperfusion and consisted of bleeding diatheses and hypocalcemia. No complications occurred in patients receiving hemodialysis (p = 0.007)., Conclusions: These data confirm that hemoperfusion provides a higher theophylline clearance rate than hemodialysis. However, hemodialysis appears to have comparable efficacy in reducing the morbidity of severe theophylline intoxication and is associated with a lower rate of procedural complications.