Use Of Hemoperfusion Research Articles

Hemoperfusion with CytoSorb® in Pediatric Patients: A Monocentric Case Series.

Background: Pro- and anti-inflammatory cytokines help regulate the inflammatory response. A cytokine storm is a dysregulated cytokine response associated with sepsis and other conditions that result in a hyper-inflammatory state. Extracorporeal cytokine adsorption has the potential to restore a balanced inflammatory response. Hemoperfusion with CytoSorb® (CS) appears to be a short-term mode of treatment of sepsis in both adults and children. Objective: We present a case series of eight critically ill children involving the use of hemoperfusion with CS at the University Medical Center Ljubljana to treat clinically manifested cytokine storm. Results: In our preliminary experience, it was applied without complication in five children weighing more than 10 kg, who all survived. The effect of age on complications regarding CS treatment is unclear, yet in our case series, all three patients weighing less than 10 kg died of their disease. Conclusions: In our preliminary experience, cytokine adsorption with CS remains a potential adjunctive treatment for cytokine storm in critically ill children.

Add-on hemoperfusion in SARS-CoV-2-infected pregnant patients: a case series

BackgroundPregnant women are more likely to have a higher severity of illness after being infected with coronavirus disease 2019 compared with the general population, particularly in the hyperinflammatory phase. However, immunomodulatory drugs are contraindicated and have been associated with an increased risk of fetal abnormalities. Therefore, we are reporting our experience with the use of HA330 hemoperfusion in combination with standard therapy in severe to critical coronavirus disease 2019 cases among pregnant patients.Case presentationFrom January 2020 to December 2021, four pregnant Thai women were treated with hemoperfusion using a cytokine adsorptive technique. The patients’ ages ranged from 21 to 36 years old, and their gestational ages at the time of admission ranged from 18 to 38 weeks. Two patients required intubation. Extracorporeal blood purification with an adsorptive cartridge (HA330®, Jafron, China) was applied as an adjunctive strategy to standard therapy approximately one week after the onset of symptoms, and most patients received three sessions of hemoperfusion. The baseline C-reactive protein level was greater than 80 mg/dL. The results showed that hemoperfusion could decrease the C-reactive protein level by approximately 80% and improve oxygenation. The newborns were delivered by Cesarean section without complications. Neither mortality nor serious adverse events related to hemoperfusion occurred.ConclusionThis report may help ensure the use of the hemoperfusion strategy in pregnant patients during a cytokine storm. However, a larger cohort is needed to confirm its safety and efficacy.

High adsorption capacity of hemoperfusion on imipenem in critically ill patients with septic shock: a case report

BackgroundSepsis is a life-threatening organ dysfunction caused by an excessive host response to infection, manifested by elevated levels of inflammatory cytokines. At present, the use of hemoperfusion to remove inflammatory cytokines from the bloodstream has been expanding. Meanwhile, the pharmacokinetics and pharmacodynamics characteristics of antibiotics in critically ill patients may be impacted by hemoperfusion.Case presentationThe patient was a 69-year-old male with poorly controlled type 2 diabetes. When admitted to the ICU, Multiple Organ Dysfunction Syndrome (MODS) appeared within 48 h, and he was suspected of septic shock due to acute granulocytopenia and significantly increased procalcitonin. Broad-spectrum antibiotics imipenem was administered according to Sepsis 3.0 bundle and hemoperfusion lasting 4 h with a neutron-macroporous resin device (HA-380, Jafron, China) five times was conducted to lower the extremely high value of serum inflammatory factors. Blood samples were collected to measure imipenem plasma concentration to investigate the effect of hemoperfusion quantitatively. This study showed that 4 h of hemoperfusion had a good adsorption ability on inflammatory factors and could remove about 75.2% of imipenem.ConclusionsThis case demonstrated the high adsorption capacity of hemoperfusion on imipenem in critically ill patients. It implies a timely imipenem supplement is required, especially before hemoperfusion.

Successful use of hemoperfusion in a pregnant woman with COVID-19 critical infection

COVID-19 is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2. Although not well established, COVID-19 infection carries a great effect on pregnant patients with increased severity compared to the nonpregnant population. Cytokine storm is a severe immune reaction and is one of the pathogeneses of COVID-19 infection. Studies have shown the benefit of hemoperfusion in managing cytokine storm, but the use in the pregnant population remains limited. We report the case of a 41-year-old pregnant woman at 25 weeks and 5 days age of gestation infected with COVID-19 presenting with difficulty of breathing and desaturation and then underwent hemoperfusion which improved her clinical condition.

Outcomes Following Hemodialysis with Hemoperfusion in Children with End-stage Kidney Disease and Moderate-to-severe COVID-19

Background: SARS-CoV-2 infection became a pandemic in the early part of 2020, affecting individuals of all ages. Patients with end-stage kidney disease (ESKD) with COVID-19 are at higher risk for morbidity and mortality. While studies support the use of hemoperfusion (HP) in patients with COVID-19, data on its use in pediatric patients are scarce and conflicting. Objectives: The objective of this study was to determine the clinical outcomes of pediatric patients with ESKD and moderate-to-severe COVID-19 who underwent hemodialysis with HP in a tertiary subspecialty hospital in Metro Manila. Methods: This retrospective cohort study included all patients with ESKD < 19 years of age admitted at the National Kidney and Transplant Institute from March 1, 2020, to March 1, 2022, on presenting with moderate-to-severe COVID-19. Data were collected through a chart review of medical records. Inflammatory markers and chest radiographs were performed at baseline and repeated after 1–4 sessions of HP. Clinical outcomes were determined in terms of discharge, duration of hospital stay, resolution of symptoms, progression of disease severity of COVID-19, and final outcome as death or discharge. Results: In eight patients who underwent the combined sessions of hemodialysis and HP, serum levels of C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, and ferritin insignificantly decreased after 2–3 sessions; the decline in procalcitonin was significant after the second session (P = 0.046). Findings of pneumonia on chest radiography decreased across all sessions. All patients showed clinical resolution of symptoms and were discharged. Conclusions: Two to three sessions of hemodialysis and HP appear to be safe in improving the clinical status of patients with ESKD and moderate-to-severe COVID-19. The combined use of these modalities can be a useful adjunct to conventional management after maximizing supportive and medical management.

#6814 A NEW SORBENT DEVICE FOR MULTIPLE CLINICAL PURPOSES: CURRENT EVIDENCE AT A PRIVATE HOSPITAL IN MEXICO

Abstract Background and Aims Adsorption is an extracorporeal technique utilized for blood purification, it also complements convection and diffusion for solute removal. Since 1991 we had used blood purification techniques, over the years, new adsorption cartridges had been developed, the new ones involving treatment for inflammatory conditions, chronic uremic symptoms and autoimmune diseases. HA130, HA230, and HA330 (Jafron, Zhuhai City, China) are among the widely used adsorption cartridges in China. We report highlights of the use of hemoperfusion using HA130 cartridges in the Mexican population cohorts in the context of multiple chronic inflammatory conditions in order to support evidence of effectiveness and safety. Method We retrospectively analyzed the medical records of 14 critically ill patients in the context of chronic inflammatory conditions such as acute kidney injury in chronic kidney disease, acute lung injury due to SARS-COV-2 infection and sepsis. Hemoperfusion in addition to standard therapy (fluid resuscitation, vasopressors, antimicrobial therapy and ventilatory support) resulted in the improvement of inflammatory substances levels when compared to standard therapy alone. Out of the 14 patients, 7 patients used HA130 cartridges and 7 patients with standard therapy alone. Results There were no significant side effects associated with HA130 cartridge use. HA 130 cartridges were found to be effective in reducing uremic symptoms in chronic hemodialysis patients, improvement of pruritus score and decreased parathyroid hormone and phosphate product (p<0.5) when compared to HD alone, creatinine (MARS: −24 μmol/L, −19.5 to −10.46, p < 0.001; SPAD: −2 μmol/L, −9.0 to +7.0/L, p = 0.314) and urea (MARS: −0.9 mmol/L, −318 to −0.189, p = 0.024; SPAD: −0.1 mmol/L, −1.0 to +0.68, p = 0.523). 66.6% of cost-effectiveness when compared to standard therapy. Conclusion In the group of patients that used HA130 cartridges we found statistically significant (p <0.05) reduction of pruritus score, PTH, phosphate product, creatine and urea when compared to the group of patients with standard therapy alone. The development in new cartridges technology allows more wide applications for renal patients. As we expand to involve other indications for this therapy there is cost-effectiveness improvement for the patients.More studies in different clinical settings are needed in order to achieve adsorption therapy national recommendations. We also found that the HA130 cartridges are effective in reducing uremic symptoms and microinflammatory status in acute kidney injury in chronic kidney disease patients due to the elimination of middle and small molecule uremic toxins and inflammatory mediators and endotoxins. This may translate as an improvement of quality of life and survive rates in patients with chronic hemodialysis, even though more studies are needed in order to prove this assumption.

#3153 HEMOPERFUSION WITH CYTOSORB AND RENAL REPLACEMENT THERAPY IN PATIENTS WITH ACUTE KIDNEY INJURY IN THE INTENSIVE CARE UNIT

Abstract Background and Aims Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious clinical disorder in the intensive care unit (ICU), occurring in a substantial proportion of critically ill patients. The aim of our single centre retrospective observational study was to analyse the outcomes of patients admitted to a non-surgical ICU and treated with RRT and with/without continuous hemoperfusion with Cytosorb. Method One hundred critically ill patients (mean age, 64.3 years; 69 men) admitted to the ICU and requiring RRT for AKI were analysed. Patient demographics, concomitant diseases, type of RRT, and survival were obtained from the medical record. APACHE II and Sofa Scores on admission were calculated. 30-day mortality was assessed using Kaplan-Meyer or Cox proportional hazards models. Results Reasons for ICU admission were acute respiratory failure (39%), cardiopulmonary resuscitation (14%), shock (13%), acute coronary syndrome (9%), sepsis (3%), acute pancreatitis (3%), and other (19%). Prior comorbidities were hypertension (70%), diabetes (43%), heart failure (32%), chronic kidney disease (CKD) (30%), coronary artery disease (CAD) (27%), chronic obstructive pulmonary disease (COPD) (15%), malignancies (12%). Eighty-six patients were treated with continuous RRT (CRRT) and 14 with intermittent hemodialysis (IHD). Twenty-four (24%) of patients treated with CRRT were also treated with hemoperfusion with Cytosorb. Using an independent-samples T test, we compared the two groups of patients with respect to the use of Cytosorb (Table 1). 30-day mortality was 82% in all patients and 87.5% in patients treated with CRRT and Cytosorb. Among concomitant diseases, only patients with previous heart failure had worse survival (p = 0.032), previous CKD, CAD, COPD, malignancy had no statistically significant impact. We found no statistically significant differences in 30-day mortality between patients treated with CRRT+Cytosorb and patients treated with CRRT or IHD alone. Multivariate Cox proportional hazard regression showed that of all the variables in the statistical model (age, sex, body mass index, previous diabetes, C-reactive protein, lactate, procalcitonin, serum creatinine, mean arterial pressure, APACHE II, ultrafiltration between CRRT), only lactate levels on admission (p = 0.002; 95%CI 1.08-1.38) were significant predictor of survival. Conclusion The use of hemoperfusion with Cytosorb in ICU patients with AKI did not reduce 30-day mortality. Patients with prior heart failure had a worse outcome. Serum lactate levels at ICU admission were an independent highly prognostic factor for death within 30 days of admission.

Hemoperfusion techniques using Jafron HA330 cartridge combined with BBraun Dialog+ dialysis machine in patient with coronavirus disease 2019 pneumonia and septic shock: a case report

BackgroundThe use of hemoperfusion for cytokine removal and inflammatory mediators is increasingly intense, especially in coronavirus disease 2019 patients who are already known to the general public for having cytokine storms. However, we have known about these cytokine storms for a long time in the critical care world. One of the modalities to remove cytokines is to use filtration and adsorption techniques with continuous renal replacement therapy. The use of continuous renal replacement therapy is usually constrained by its very high cost compared with standard care, especially in Indonesia, where health costs are covered by national health insurance. In this case, we use hemodialysis and hemoperfusion, using a dialysis machine, which is more cost-effective and easy to use.Case presentationWe used the Jafron HA330 cartridge, modified for the BBraun Dialog+ dialysis machine. This case report presents an 84-year-old Asian man with septic shock due to pneumonia, congestive heart failure, and acute chronic kidney disease accompanied by fluid overload. After undergoing hemodialysis and hemoperfusion separately, there was a gradual and significant clinical improvement. Clinical indicators, including the vasopressor inotropic score and infection markers, should all be considered when deciding whether to begin hemodialysis and hemoperfusion.ConclusionIn general, using hemoperfusion to treat septic shock patients can reduce the length of stay in the intensive care unit, and morbidity and mortality.

Role of hemoperfusion combined with hemodialysis in acute severe organophosphorus pesticide poisoning: a meta-analysis

Abstract Background Acute severe organophosphorus pesticide poisoning is a common severe emergency in developing countries. Our meta-analysis aimed to clarify the efficacy of hemoperfusion combined with hemodialysis on acute severe organophosphorus pesticide poisoning. Methods Several databases were searched. After formulating relevant inclusion and exclusion criteria, qualified studies were included, and the data were extracted. The outcome indicators were the success rate of rescue, the time of hospitalization, the incidence of complications, the time for the cholinesterase level to return to normal, the coma time, and the atropine dosage. The results were analyzed using risk ratios, weighted mean difference, standard mean difference, and 95% confidence interval. The Cochrane Collaboration tool was used to assess the risk of bias in all the included studies. In terms of statistical methods, we used RevMan software (version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) and Stata (versions 14 and 16; StataCorp, College Station, TX, USA) for the data analysis. Results We included 92 randomized controlled trials with 6899 participants. Compared with the conventional emergency treatment group (CET group), the hemoperfusion group (HP + CET group), and the hemodialysis group (HD + CET group), the use of hemoperfusion combined with hemodialysis based on CET (HP + HD + CET group) significantly increased the success rate of rescue and reduced hospitalization time, the incidence of complications, time for cholinesterase level to return to normal, coma time, and atropine dosage. Conclusion Hemoperfusion combined with hemodialysis is effective in the treatment of acute severe organophosphorus pesticide poisoning. In the future, more scientifically designed, large-scale, high-quality, multicenter randomized controlled trials are needed to validate this study further.

Think Global, Act Local

Think Global, Act Local

Clinical efficacy of hemoperfusion with a cytokine adsorbent in norepinephrine-resistant septic shock: protocol for the CLEANSE randomized clinical trial

Background: Due to the pivotal role of inflammatory cytokines in sepsis, hemoperfusion with cytokine adsorbents may lead to better outcomes. Although previous studies showed inconclusive results, proper patient selection and timing of hemoperfusion may lead to improved survival. Objectives: To examine whether patients with septic shock requiring high-dose vasopressors undergoing add-on hemoperfusion with a cytokine adsorbent have better clinical outcomes than those treated with standard treatment alone. Methods: This is a multi-center, randomized controlled study in 2 tertiary care centers. 206 patients with septic shock receiving norepinephrine of 0.2 mcg/kg/min or higher are randomized to receive either standard treatment combined with 3-hour sessions of hemoperfusion with cytokine adsorbent for two consecutive days (HP group) or standard treatment alone (ST group). The primary outcome is 28-day mortality. Secondary outcomes include hospital and ICU mortality, shock reversal, vasoactive-inotropic score (VIS), organ support-free days, interleukin-6 levels, as well as safety data. Conclusions: This study will provide information to guide the use of hemoperfusion with a cytokine adsorbent in patients with septic shock.

ИЗМЕНЕНИЕ КОНЦЕНТРАЦИИ В ПЛАЗМЕ МЕРОПЕНЕМА НА ФОНЕ ПРОВЕДЕНИЯ ЭКСТРАКОРПОРАЛЬНОЙ ГЕМОПЕРФУЗИИ ЧЕРЕЗ СЕЛЕКТИВНЫЕ ГЕМОСОРБЕНТЫ У ПАЦИЕНТОВ С СЕПСИСОМ ПРИ ПРОВЕДЕНИИ КОМПЛЕКСНОЙ ИНТЕНСИВНОЙ ТЕРАПИИ

Background. Sepsis and septic shock are the main causes of death in intensive care units. Hemoperfusion in combination with standard therapy of sepsis reduces mortality by an average of 5-7%, however, there is evidence that hemosorbents can reduce plasma levels of antibacterial drugs. Purpose of the study. Our aim is to investigate the effect of hemoperfusion on the meropenem plasma levels using the sorbents “Hemoproteazosorb” and “LPS-hemo”. Material and methods. 35 patients with sepsis were examined: a control group without the use of hemoperfusion and two experimental groups, in which hemoperfusion with various sorbents was used. Plasma concentration of meropenem was determined by ELISA. Results. In the control group, a decrease in concentration of meropenem was observed in 27% of cases (decrease value 3.81 µg/ml; p<0.25). In the group of “Hemoproteazosorb” - in 54% of cases after hemosorption (1.33 µg/ml; p<0.02); in “LPS-hemo” group - in 50% of cases (3.08 µg/ml; p<0.06). Conclusions. Hemoadsorption can alter the plasma concentration of meropenem, it is necessary to develop methods of correction such as modifying dosing regimens of an antibacterial drug.

Efficacy of Hemoperfusion in Severe and Critical Cases of COVID-19

Introduction: Uncontrolled overproduction of inflammatory mediators is predominantly observed in patients with severe COVID-19. The excessive immune response gives rise to multiple organ dysfunction. Implementing extracorporeal therapies may be useful in omitting inflammatory mediators and supporting different organ systems. We aimed to investigate the effectiveness of hemoperfusion in combination with standard therapy in critically ill COVID-19 patients. Method: We conducted a single-center, matched control retrospective study on patients with confirmed SARS-CoV-2 infection. Patients were treated with hemoperfusion in combination with standard therapy (hemoperfusion group) or standard treatment (matched group). Hemoperfusion or hemoperfusion and continuous renal replacement therapies were initiated in the hemoperfusion group. The patients in the matched group were matched one by one with the hemoperfusion group for age, sex, oxygen saturation (SPO2) at the admission, and the frequency of using invasive mechanical ventilation during hospitalization. Two types of hemoperfusion cartridges used in this study were Jafron^© (HA330) and CytoSorb® 300. Result: A total of 128 COVID-19-confirmed patients were enrolled in this study; 73 patients were allotted to the matched group and 55 patients received hemoperfusion. The median SPO2 at the admission day in the control and hemoperfusion groups was 80% and 75%, respectively (p value = 0.113). The mortality rate was significantly lower in the hemoperfusion group compared to the matched group (67.3% vs. 89%; p value = 0.002). The median length of ICU stay was statistically different in studied groups (median, 12 days for hemoperfusion group vs. 8 days for the matched group; p < 0.001). The median final SPO2 was statistically higher in the hemoperfusion group than in the matched group, and the median PaCO2 was lower. Conclusion: Among critically ill COVID-19 patients, based on our study, the use of hemoperfusion may reduce the mortality rate and improve SPO2 and PaCO2.

A Review of the Potential of Hemoperfusion for the Treatment of Patients with Respiratory Infectious Diseases with COVID-19 Approach

Severe infection with COVID-19 disease can be associated with respiratory failure, kidney disorders, and in more advanced stages, organ failure and death. Unfortunately, there is currently no definitive cure for this disease, and damage to the immune system caused by inflammatory storms leads to widespread and varied complications that make an early diagnosis of the disease difficult. Therefore, eliminating or inhibiting the production of factors involved in inflammatory storms can be effective in improving the clinical condition of patients. According to specialized studies on the role of hemoperfusion in inhibiting advanced levels of COVID-19 disease, the present study was performed to investigate the use of hemoperfusion as a potential treatment option for this disease.

Haemoperfusion should only be used for COVID-19 in the context ofrandomized trials.

Interest in the use of haemoperfusion for severe COVID-19 has been spurred by anecdotal reports of its efficacy and expert reviews suggesting theoretical benefits. However, on the basis of the limited current evidence, haemoperfusion remains an experimental therapy that should only be applied within the context of well-designed randomized trials.

The effect of hemoperfusion on the recovery of COVID-19 in hospitalized patients; case series and review study

Hemoperfusion is an effective modality in removing certain toxins from the blood, especially those that bind to proteins in the body. Hemoperfusion has shown a therapeutic effect on COVID-19 patients. In this case series, we report four patients without effective results following the use of hemoperfusion on the recovery of COVID-19 patients. This study is a case series which carried out on four patients referred to COVID-19 ward of Velayat hospital in Qazvin, Iran. The mean age of the COVID-19 patients was 52.75 ± 18 years. The mean stay at the hospital was 21.5 ± 15.15 days. This study showed that hemoperfusion cannot show a significant therapeutic effect on COVID-19.

P1114HA-130 HEMOPERFUSION CARTRIDGE IN THE TREATMENT OF CAST NEPHROPATHY IN A 58-YEAR-OLD MALE WITH MULTIPLE MYELOMA: A CASE REPORT

Abstract Background and Aims Multiple myeloma is a plasma cell neoplasm that results in the production of monoclonal immunoglobulin. Renal failure is a common complication of multiple myeloma, occurring in approximately one-half of patients on initial presentation and is associated with increased mortality. Cast nephropathy in particular, is considered to be one of the major mechanisms of renal failure in multiple myeloma, and is characterized by precipitation of free light chains in the distal nephron, leading to intratubular obstruction, inflammation and fibrosis. Recent studies have demonstrated the use of extracorporeal methods such as plasmapheresis and high-cutoff membrane dialysis as an adjunctive therapy to chemotherapy in the management of cast nephropathy, however currently there are no existing guidelines in the use of extracorporeal therapies in the management of complications of multiple myeloma. Hemoperfusion is an extracorporeal treatment technique which utilizes adsorption in the removal of specific toxins. The HA 130 cartridge in particular has a resin pore size distribution of 500Da- 40 KDa and is able to remove molecules at 5-30kDa. In this case report we describe the use of HA 130 hemoperfusion cartridge in the treatment of cast nephropathy in Multiple Myeloma. Method A 58-year-old male, diabetic, non-hypertensive came in for 5-day history of generalized body weakness, associated with myalgia, lumbar pain and undocumented fever, with 1-day history of loose stools and vomiting. Upon admission blood tests done revealed anemia with a hemoglobin of 7.8g/dl, creatinine of 9.97mg/dL and potassium of 5.5mmol/L. He was diagnosed with acute renal failure and underwent hemodialysis on the second hospital day. On workup he had lytic bone lesions in the spine, pelvis and cranium on CT scan and x-ray. Serum Protein Electrophoresis (SPEP) and Serum Free Light Chain (sFLC) tests showed a monoclonal gammopathy. Serum beta 2 microglobulin was elevated at 12,618ng/ml. Free kappa and lambda light chains were also elevated at 19,250mg/L and 25.7mg/L, respectively. Bone marrow biopsy was done, with findings of markedly hypercellular marrow with 80% plasma cells confirming the diagnosis of Multiple Myeloma. Combined hemodialysis with hemoperfusion were done using HA 130 filter and hi flux dialyzer for 2.5 hours then hemodialysis for three times a week. Patient was also started on chemotherapy using Bortezomib with Dexamethasone for 2 cycles. Results Patient had a total of 14 sessions of combined hemoperfusion with hemodialysis. On repeat free kappa light chains decreased to 212.5mg/L. Patient was maintained on hemodialysis three times a week and was discharged after 55 hospital days. Outpatient hemodialysis was continued three times a week, and after 2 weeks, patient showed signs of renal recovery with a repeat creatinine of 2.1mg/dL. Four weeks after discharge, patient was independent of hemodialysis with a repeat creatinine of 1.3mg/dL. Conclusion This report highlights the use of hemoperfusion using HA 130 cartridge in combination with chemotherapy using Bortezomib in reducing free light chain levels in a 58-year-old male that developed renal failure secondary to cast nephropathy. Patient was able to achieve reduction in free light chain levels, improvement in renal function and eventually independence from hemodialysis four weeks after the last hemoperfusion treatment. Further studies using a randomized control trial on the use of hemoperfusion in directly reducing serum free light chain levels is recommended. The value of hemoperfusion on the rate of independence from hemodialysis, as well as survival rates among patients with renal failure secondary to multiple myeloma may also be worth investigating using larger studies.

Blood Purification and Mortality in Sepsis and Septic Shock: A Systematic Review and Meta-analysis of Randomized Trials.

Sepsis and septic shock are severe inflammatory conditions related to high morbidity and mortality. We performed a systematic review with meta-analysis of randomized trials to assess whether extracorporeal blood purification reduces mortality in this setting. Electronic databases were searched for pertinent studies up to January 2019. We included randomized controlled trials on the use of hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique in comparison to conventional therapy in adult patients with sepsis and septic shock. The primary outcome was mortality at the longest follow-up available. We calculated relative risks and 95% CIs. The grading of recommendations assessment, development and evaluation methodology for the certainty of evidence was used. Thirty-seven trials with 2,499 patients were included in the meta-analysis. Hemoperfusion was associated with lower mortality compared to conventional therapy (relative risk = 0.88 [95% CI, 0.78 to 0.98], P = 0.02, very low certainty evidence). Low risk of bias trials on polymyxin B immobilized filter hemoperfusion showed no mortality difference versus control (relative risk = 1.14 [95% CI, 0.96 to 1.36], P = 0.12, moderate certainty evidence), while recent trials found an increased mortality (relative risk = 1.22 [95% CI, 1.03 to 1.45], P = 0.02, low certainty evidence); trials performed in the United States and Europe had no significant difference in mortality (relative risk = 1.13 [95% CI, 0.96 to 1.34], P = 0.15), while trials performed in Asia had a positive treatment effect (relative risk = 0.57 [95% CI, 0.47 to 0.69], P < 0.001). Hemofiltration (relative risk = 0.79 [95% CI, 0.63 to 1.00], P = 0.05, very low certainty evidence) and plasmapheresis (relative risk = 0.63 [95% CI, 0.42 to 0.96], P = 0.03, very low certainty evidence) were associated with a lower mortality. Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock. Existing evidence of moderate quality and certainty does not provide any support for a difference in mortality using polymyxin B hemoperfusion. Further high-quality randomized trials are needed before systematic implementation of these therapies in clinical practice.

Paraquat: The Poison Potion.

ABSTRACTParaquat is a commonly used herbicide in India that has lethal consequences even on minimal consumption. The case fatality rate for this poisoning is high and there is dearth of evidence-based recommendation for the treatment of this poison. This review article explores the diagnosis and management of paraquat poisoning with an emphasis on recent advances in treatment. Though immunosuppressants and antioxidants are conventionally used, there is a gap in evidence to prove survival benefit of these treatment regimens. There are also some data showing the use of hemoperfusion (with toxin-specific cartridges) as an early intervention, i.e., within 4 hours of exposure to the poison. The recent drug, Edaravone, has also shown promise in the prevention of renal and hepatic injury in paraquat poisoning. Though it did not reduce pulmonary fibrosis in patients with paraquat poisoning, it delays the generation and development of pulmonary fibrosis. However, there is a need for more clinical and experimental studies to validate its use in paraquat poisoning.How to cite this articleSukumar CA, Shanbhag V, Shastry AB. Paraquat: The Poison Potion. Indian J Crit Care Med 2019;23(Suppl 4):S263–S266.

Extracorporeal Sorbent Technologies: Basic Concepts and Clinical Application.

Limitations imposed by the characteristics of some solutes and the structure of dialysis membranes have spurred new interest in the use of mechanisms beyond diffusion and convection for extracorporeal solute removal. Sorbents have been utilized for more than 50 years in extracorporeal blood treatments for specific purposes, and better understanding of their basic aspects may further expand the potential for their clinical application. In this chapter, the basic principles applying to sorbents are discussed, including composition and structure, along with the fundamental mechanisms of solute removal. The critical importance of sorbent biocompatibility is also highlighted. With these basic principles in mind, the clinical application of sorbents is discussed, with an emphasis on the use of hemoperfusion and coupled plasma filtration-adsorption for sepsis-related disorders. Finally, new sorbent-based clinical approaches for acute conditions and end-stage renal disease are presented, emphasizing that sorbent technologies may assume a larger role for a variety of clinical disorders in the future.