Top

Published in:

01-02-2011 | Review

Clinical review: Blood purification for sepsis

Authors: Thomas Rimmelé, John A Kellum

Published in: Critical Care | Issue 1/2011

Abstract

Sepsis is the primary cause of death in the intensive care unit. Extracorporeal blood purification therapies have been proposed for patients with sepsis in order to improve outcomes since these therapies can alter the host inflammatory response by non-selective removal of inflammatory mediators or bacterial products or both. Recent technological progress has increased the number of techniques available for blood purification and their performance. In this overview, we report on the latest advances in blood purification for sepsis and how they relate to current concepts of disease, and we review the current evidence for high-volume hemofiltration, cascade hemofiltration, hemoadsorption, coupled plasma filtration adsorption, high-adsorption hemofiltration, and high-cutoff hemofiltration/hemodialysis. Promising results have been reported with all of these blood purification therapies, showing that they are well tolerated, effective in clearing inflammatory mediators or bacterial toxins (or both) from the plasma, and efficacious for improvement of various physiologic outcomes (for example, hemodynamics and oxygenation). However, numerous questions, including the timing, duration, and frequency of these therapies in the clinical setting, remain unanswered. Large multicenter trials evaluating the ability of these therapies to improve clinical outcomes (that is, mortality or organ failure), rather than surrogate markers such as plasma mediator clearance or transient improvement in physiologic variables, are required to define the precise role of blood purification in the management of sepsis.

Available only for authorised users

Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001, 29: 1303-1310.PubMedCrossRef

Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D: Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006, 34: 344-353.PubMedCrossRef

Suntharalingam G, Perry MR, Ward S, Brett SJ, Castello-Cortes A, Brunner MD, Panoskaltsis N: Cytokine storm in a phase 1 trial of the anti-CD28 monoclonal antibody TGN1412. N Engl J Med 2006, 355: 1018-1028.PubMedCrossRef

Hotchkiss RS, Coopersmith CM, McDunn JE, Ferguson TA: The sepsis seesaw: tilting toward immunosuppression. Nat Med 2009, 15: 496-497.PubMedPubMedCentralCrossRef

Limaye AP, Kirby KA, Rubenfeld GD, Leisenring WM, Bulger EM, Neff MJ, Gibran NS, Huang ML, Santo Hayes TK, Corey L, Boeckh M: Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA 2008, 300: 413-422.PubMedPubMedCentralCrossRef

Luyt CE, Combes A, Deback C, Aubriot-Lorton MH, Nieszkowska A, Trouillet JL, Capron F, Agut H, Gibert C, Chastre J: Herpes simplex virus lung infection in patients undergoing prolonged mechanical ventilation. Am J Respir Crit Care Med 2007, 175: 935-942.PubMedCrossRef

Tetta C, Bellomo R, Inguaggiato P, Wratten ML, Ronco C: Endotoxin and cytokine removal in sepsis. Ther Apher 2002, 6: 109-115.PubMedCrossRef

Deans KJ, Haley M, Natanson C, Eichacker PQ, Minneci PC: Novel therapies for sepsis: a review. J Trauma 2005, 58: 867-874.PubMedCrossRef

Ronco C, Tetta C, Mariano F, Wratten ML, Bonello M, Bordoni V, Cardona X, Inguaggiato P, Pilotto L, d'Intini V, Bellomo R: Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003, 27: 792-801.PubMedCrossRef

10.

Honoré PM, Matson JR: Extracorporeal removal for sepsis: acting at the tissue level--the beginning of a new era for this treatment modality in septic shock. Crit Care Med 2004, 32: 896-897.PubMedCrossRef

11.

Di Carlo JV, Alexander SR: Hemofiltration for cytokine-driven illnesses: the mediator delivery hypothesis. Int J Artif Organs 2005, 28: 777-786.PubMed

12.

Peng Z, Singbartl K, Simon P, Rimmele T, Bishop J, Clermont G, Kellum JA: Blood purification in sepsis: a new paradigm. Contrib Nephrol 2010, 165: 322-328.PubMedCrossRef

13.

Ono S, Tsujimoto H, Matsumoto A, Ikuta S, Kinoshita M, Mochizuki H: Modulation of human leukocyte antigen-DR on monocytes and CD16 on granulocytes in patients with septic shock using hemoperfusion with polymyxin B-immobilized fiber. Am J Surg 2004, 188: 150-156.PubMedCrossRef

14.

Call DR, Nemzek JA, Ebong SJ, Bolgos GL, Newcomb DE, Remick DG: Ratio of local to systemic chemokine concentrations regulates neutrophil recruitment. Am J Pathol 2001, 158: 715-721.PubMedPubMedCentralCrossRef

15.

De Vriese AS, Vanholder RC, Pascual M, Lameire NH, Colardyn FA: Can inflammatory cytokines be removed efficiently by continuous renal replacement therapies? Intensive Care Med 1999, 25: 903-910.PubMedCrossRef

16.

Kellum JA, Johnson JP, Kramer D, Palevsky P, Brady JJ, Pinsky MR: Diffusive vs. convective therapy: effects on mediators of inflammation in patient with severe systemic inflammatory response syndrome. Crit Care Med 1998, 26: 1995-2000.PubMedCrossRef

17.

Honoré PM, Joannes-Boyau O, Kotulak T: Report of the working party on high volume hemofiltration including definitions and classification. Proc 2nd Czech Conference on Critical Care Nephrology (Pardubice, Czech Republic) 2007.

18.

Brendolan A, D'Intini V, Ricci Z, Bonello M, Ratanarat R, Salvatori G, Bordoni V, De Cal M, Andrikos E, Ronco C: Pulse high volume hemofiltration. Int J Artif Organs 2004, 27: 398-403.PubMed

19.

Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C: The first international consensus conference on continuous renal replacement therapy. Kidney Int 2002, 62: 1855-1863.PubMedCrossRef

20.

Kellum JA, Ronco C: Dialysis: results of RENAL--What is the optimal CRRT target dose? Nat Rev Nephrol 2010, 6: 191-192.PubMedCrossRef

21.

Grootendorst AF, van Bommel EF, van der Hoven B, van Leengoed LA, van Osta AL: High volume hemofiltration improves right ventricular function in endotoxin-induced shock in the pig. Intensive Care Med 1992, 18: 235-240.PubMedCrossRef

22.

Li CM, Chen JH, Zhang P, He Q, Yuan J, Chen RJ, Cheng XJ, Tan HZ, Yang Y: Continuous veno-venous haemofiltration attenuates myocardial mitochondrial respiratory chain complexes activity in porcine septic shock. Anaesth Intensive Care 2007, 35: 911-919.PubMed

23.

Sykora R, Chvojka J, Krouzecky A, Radej J, Karvunidis T, Varnerova V, Novak I, Matejovic M: High versus standard-volume haemofiltration in hyperdynamic porcine peritonitis: effects beyond haemodynamics? Intensive Care Med 2009, 35: 371-380.PubMedCrossRef

24.

Bellomo R, Kellum JA, Gandhi CR, Pinsky MR, Ondulik B: The effect of intensive plasma water exchange by hemofiltration on hemodynamics and soluble mediators in canine endotoxemia. Am J Respir Crit Care Med 2000, 161: 1429-1436.PubMedCrossRef

25.

Lee PA, Matson JR, Pryor RW, Hinshaw LB: Continuous arteriovenous hemofiltration therapy for Staphylococcus aureus -induced septicemia in immature swine. Crit Care Med 1993, 21: 914-924.PubMedCrossRef

26.

Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P: High-volume haemofiltration in human septic shock. Intensive Care Med 2001, 27: 978-986.PubMedCrossRef

27.

Boussekey N, Chiche A, Faure K, Devos P, Guery B, d'Escrivan T, Georges H, Leroy O: A pilot randomized study comparing high and low volume hemofiltration on vasopressor use in septic shock. Intensive Care Med 2008, 34: 1646-1653.PubMedCrossRef

28.

Cornejo R, Downey P, Castro R, Romero C, Regueira T, Vega J, Castillo L, Andresen M, Dougnac A, Bugedo G, Hernandez G: High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock. Intensive Care Med 2006, 32: 713-722.PubMedCrossRef

29.

Honoré PM, Jamez J, Wauthier M, Lee PA, Dugernier T, Pirenne B, Hanique G, Matson JR: Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med 2000, 28: 3581-3587.PubMedCrossRef

30.

Joannes-Boyau O, Rapaport S, Bazin R, Fleureau C, Janvier G: Impact of high volume hemofiltration on hemodynamic disturbance and outcome during septic shock. Asaio J 2004, 50: 102-109.PubMedCrossRef

31.

Oudemans-van Straaten HM, Bosman RJ, van der Spoel JI, Zandstra DF: Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis. Intensive Care Med 1999, 25: 814-821.PubMedCrossRef

32.

Piccinni P, Dan M, Barbacini S, Carraro R, Lieta E, Marafon S, Zamperetti N, Brendolan A, D'Intini V, Tetta C, Bellomo R, Ronco C: Early isovolaemic haemofiltration in oliguric patients with septic shock. Intensive Care Med 2006, 32: 80-86.PubMedCrossRef

33.

Ratanarat R, Brendolan A, Piccinni P, Dan M, Salvatori G, Ricci Z, Ronco C: Pulse high-volume haemofiltration for treatment of severe sepsis: effects on hemodynamics and survival. Crit Care 2005, 9: R294-302.PubMedPubMedCentralCrossRef

34.

Jiang HL, Xue WJ, Li DQ, Yin AP, Xin X, Li CM, Gao JL: Influence of continuous veno-venous hemofiltration on the course of acute pancreatitis. World J Gastroenterol 2005, 11: 4815-4821.PubMedPubMedCentralCrossRef

35.

Laurent I, Adrie C, Vinsonneau C, Cariou A, Chiche JD, Ohanessian A, Spaulding C, Carli P, Dhainaut JF, Monchi M: High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study. J Am Coll Cardiol 2005, 46: 432-437.PubMedCrossRef

36.

Cole L, Bellomo R, Hart G, Journois D, Davenport P, Tipping P, Ronco C: A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med 2002, 30: 100-106.PubMedCrossRef

37.

Payen D, Mateo J, Cavaillon JM, Fraisse F, Floriot C, Vicaut E: Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med 2009, 37: 803-810.PubMedCrossRef

38.

Bellomo R, Tan HK, Bhonagiri S, Gopal I, Seacombe J, Daskalakis M, Boyce N: High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance. Int J Artif Organs 2002, 25: 261-268.PubMed

39.

Srisawat N, Lawsin L, Uchino S, Bellomo R, Kellum JA: Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study. Crit Care 2010, 14: R46.PubMedPubMedCentralCrossRef

40.

Rimmelé T, Wey PF, Bernard N, Monchi M, Semenzato N, Benatir F, Boselli E, Etienne J, Goudable J, Chassard D, Bricca G, Allaouchiche B: Hemofiltration with the Cascade system in an experimental porcine model of septic shock. Ther Apher Dial 2009, 13: 63-70.PubMedCrossRef

41.

Winchester JF, Kellum JA, Ronco C, Brady JA, Quartararo PJ, Salsberg JA, Levin NW: Sorbents in acute renal failure and the systemic inflammatory response syndrome. Blood Purif 2003, 21: 79-84.PubMedCrossRef

42.

Shoji H: Extracorporeal endotoxin removal for the treatment of sepsis: endotoxin adsorption cartridge (Toraymyxin). Ther Apher Dial 2003, 7: 108-114.PubMedCrossRef

43.

Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, Malcangi V, Petrini F, Volta G, Bobbio Pallavicini FM, Rottoli F, Giunta F, Ronco C: Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009, 301: 2445-2452.PubMedCrossRef

44.

Kellum JA, Uchino S: International differences in the treatment of sepsis: are they justified? JAMA 2009, 301: 2496-2497.PubMedCrossRef

45.

Vincent JL, Laterre PF, Cohen J, Burchardi H, Bruining H, Lerma FA, Wittebole X, De Backer D, Brett S, Marzo D, Nakamura H, John S: A pilot-controlled study of a polymyxin B-immobilized hemoperfusion cartridge in patients with severe sepsis secondary to intra-abdominal infection. Shock 2005, 23: 400-405.PubMedCrossRef

46.

Cruz DN, Perazella MA, Bellomo R, de Cal M, Polanco N, Corradi V, Lentini P, Nalesso F, Ueno T, Ranieri VM, Ronco C: Effectiveness of polymyxin B-immobilized fiber column in sepsis: a systematic review. Crit Care 2007, 11: R47.PubMedPubMedCentralCrossRef

47.

Kellum JA, Song M, Venkataraman R: Hemoadsorption removes tumor necrosis factor, interleukin-6, and interleukin-10, reduces nuclear factor-kappaB DNA binding, and improves short-term survival in lethal endotoxemia. Crit Care Med 2004, 32: 801-805.PubMedCrossRef

48.

Peng ZY, Carter MJ, Kellum JA: Effects of hemoadsorption on cytokine removal and short-term survival in septic rats. Crit Care Med 2008, 36: 1573-1577.PubMedPubMedCentralCrossRef

49.

Taniguchi T, Hirai F, Takemoto Y, Tsuda K, Yamamoto K, Inaba H, Sakurai H, Furuyoshi S, Tani N: A novel adsorbent of circulating bacterial toxins and cytokines: the effect of direct hemoperfusion with CTR column for the treatment of experimental endotoxemia. Crit Care Med 2006, 34: 800-806.PubMed

50.

Taniguchi T, Kurita A, Mukawa C, Yamamoto K, Inaba H: Dose-related effects of direct hemoperfusion using a cytokine adsorbent column for the treatment of experimental endotoxemia. Intensive Care Med 2007, 33: 529-533.PubMedCrossRef

51.

Bengsch S, Boos KS, Nagel D, Seidel D, Inthorn D: Extracorporeal plasma treatment for the removal of endotoxin in patients with sepsis: clinical results of a pilot study. Shock 2005, 23: 494-500.PubMed

52.

Busund R, Koukline V, Utrobin U, Nedashkovsky E: Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial. Intensive Care Med 2002, 28: 1434-1439.PubMedCrossRef

53.

Eguchi Y: Plasma dia-filtration for severe sepsis. Contrib Nephrol 2010, 166: 142-149.PubMedCrossRef

54.

Reeves JH, Butt WW, Shann F, Layton JE, Stewart A, Waring PM, Presneill JJ: Continuous plasmafiltration in sepsis syndrome. Plasmafiltration in Sepsis Study Group. Crit Care Med 1999, 27: 2096-2104.PubMedCrossRef

55.

Toft P, Schmidt R, Broechner AC, Nielsen BU, Bollen P, Olsen KE: Effect of plasmapheresis on the immune system in endotoxin-induced sepsis. Blood Purif 2008, 26: 145-150.PubMedCrossRef

56.

McMaster P, Shann F: The use of extracorporeal techniques to remove humoral factors in sepsis. Pediatr Crit Care Med 2003, 4: 2-7.PubMedCrossRef

57.

Valbonesi M, Pallavicini FB, Cannella G, Zinno E, Patrone F, Carlier P, Dejana A, Morelli F: MOF induced by meningococcal sepsis: successful outcome after intensive multidisciplinary approaches. Transfus Apher Sci 2005, 33: 75-77.PubMedCrossRef

58.

Hjorth V, Stenlund G: Plasmapheresis as part of the treatment for septic shock. Scand J Infect Dis 2000, 32: 511-514.PubMedCrossRef

59.

Carcillo JA, Kellum JA: Is there a role for plasmapheresis/plasma exchange therapy in septic shock, MODS, and thrombocytopenia-associated multiple organ failure? We still do not know--but perhaps we are closer. Intensive Care Med 2002, 28: 1373-1375.PubMedCrossRef

60.

Cole L, Bellomo R, Davenport P, Tipping P, Uchino S, Tetta C, Ronco C: The effect of coupled haemofiltration and adsorption on inflammatory cytokines in an ex vivo model. Nephrol Dial Transplant 2002, 17: 1950-1956.PubMedCrossRef

61.

Ronco C, Brendolan A, Lonnemann G, Bellomo R, Piccinni P, Digito A, Dan M, Irone M, La Greca G, Inguaggiato P, Maggiore U, De Nitti C, Wratten ML, Ricci Z, Tetta C: A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med 2002, 30: 1250-1255.PubMedCrossRef

62.

Formica M, Olivieri C, Livigni S, Cesano G, Vallero A, Maio M, Tetta C: Hemodynamic response to coupled plasmafiltration-adsorption in human septic shock. Intensive Care Med 2003, 29: 703-708.PubMed

63.

Tetta C, Gianotti L, Cavaillon JM, Wratten ML, Fini M, Braga M, Bisagni P, Giavaresi G, Bolzani R, Giardino R: Coupled plasma filtration-adsorption in a rabbit model of endotoxic shock. Crit Care Med 2000, 28: 1526-1533.PubMedCrossRef

64.

Lentini P, Cruz D, Nalesso F, de Cal M, Bobek I, Garzotto F, Zanella M, Brendolan A, Piccinni P, Ronco C: [A pilot study comparing pulse high volume hemofiltration (pHVHF) and coupled plasma filtration adsorption (CPFA) in septic shock patients] [in Italian]. G Ital Nefrol 2009, 26: 695-703.PubMed

65.

Stengl M, Sykora R, Chvojka J, Krouzecky A, Novak I, Varnerova V, Kuncova J, Nalos L, Sviglerova J, Matejovic M: Differential effects of hemofiltration and of coupled plasma filtration adsorption on cardiac repolarization in pigs with hyperdynamic septic shock. Shock 2010, 33: 101-105.PubMedCrossRef

66.

Mao HJ, Yu S, Yu XB, Zhang B, Zhang L, Xu XR, Wang XY, Xing CY: Effects of coupled plasma filtration adsorption on immune function of patients with multiple organ dysfunction syndrome. Int J Artif Organs 2009, 32: 31-38.PubMed

67.

Rimmele T, Assadi A, Cattenoz M, Desebbe O, Lambert C, Boselli E, Goudable J, Etienne J, Chassard D, Bricca G, Allaouchiche B: High-volume haemofiltration with a new haemofiltration membrane having enhanced adsorption properties in septic pigs. Nephrol Dial Transplant 2009, 24: 421-427.PubMedCrossRef

68.

Joannes-Boyau O, Honoré PM, Boer W, Collin V: Are the synergistic effects of high-volume haemofiltration and enhanced adsorption the missing key in sepsis modulation? Nephrol Dial Transplant 2009, 24: 354-357.PubMedCrossRef

69.

Uchino S, Bellomo R, Goldsmith D, Davenport P, Cole L, Baldwin I, Panagiotopoulos S, Tipping P: Super high flux hemofiltration: a new technique for cytokine removal. Intensive Care Med 2002, 28: 651-655.PubMedCrossRef

70.

Haase M, Bellomo R, Morgera S, Baldwin I, Boyce N: High cut-off point membranes in septic acute renal failure: a systematic review. Int J Artif Organs 2007, 30: 1031-1041.PubMed

71.

Lee PA, Weger GW, Pryor RW, Matson JR: Effects of filter pore size on efficacy of continuous arteriovenous hemofiltration therapy for Staphylococcus aureus -induced septicemia in immature swine. Crit Care Med 1998, 26: 730-737.PubMedCrossRef

72.

Morgera S, Haase M, Kuss T, Vargas-Hein O, Zuckermann-Becker H, Melzer C, Krieg H, Wegner B, Bellomo R, Neumayer HH: Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure. Crit Care Med 2006, 34: 2099-2104.PubMedCrossRef

73.

Morgera S, Haase M, Rocktaschel J, Bohler T, von Heymann C, Vargas-Hein O, Krausch D, Zuckermann-Becker H, Muller JM, Kox WJ, Neumayer HH: High permeability haemofiltration improves peripheral blood mononuclear cell proliferation in septic patients with acute renal failure. Nephrol Dial Transplant 2003, 18: 2570-2576.PubMedCrossRef

74.

Morgera S, Klonower D, Rocktaschel J, Haase M, Priem F, Ziemer S, Wegner B, Gohl H, Neumayer HH: TNF-alpha elimination with high cut-off haemofilters: a feasible clinical modality for septic patients? Nephrol Dial Transplant 2003, 18: 1361-1369.PubMedCrossRef

75.

Haase M, Bellomo R, Baldwin I, Haase-Fielitz A, Fealy N, Davenport P, Morgera S, Goehl H, Storr M, Boyce N, Neumayer HH: Hemodialysis membrane with a high-molecular-weight cutoff and cytokine levels in sepsis complicated by acute renal failure: a phase 1 randomized trial. Am J Kidney Dis 2007, 50: 296-304.PubMedCrossRef

76.

Lee D, Haase M, Haase-Fielitz A, Paizis K, Goehl H, Bellomo R: A pilot, randomized, double-blind, cross-over study of high cut-off versus high-flux dialysis membranes. Blood Purif 2009, 28: 365-372.PubMedCrossRef

77.

Zhu Y, Zhang P, Yuan J, He Q, Jiang H, Hu X, Chen J: Adjunctive continuous high-volume hemofiltration in acute severe pancreatitis patients: a retrospective study. Scand J Gastroenterol 2009, 44: 1363-1369.PubMedCrossRef

Title: Clinical review: Blood purification for sepsis
Authors: Thomas Rimmelé
John A Kellum
Publication date: 01-02-2011
Publisher: BioMed Central
Published in: Critical Care / Issue 1/2011
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc9411

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Clinical review: Blood purification for sepsis

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2011

PCR for the diagnosis of sepsis: hope or hype?

Too early initiation of renal replacement therapy may be harmful

Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients

The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest

Pulse contour analysis: Is it able to reliably detect changes in cardiac output in the haemodynamically unstable patient?

Pro/con debate: Continuous versus intermittent dialysis for acute kidney injury: a never-ending story yet approaching the finish?