Blood purification and mortality in sepsis: a meta-analysis of randomized trials

Abstract

Objectives: Although blood purification improves outcomes in animal studies of sepsis, results of clinical trials have been mixed. We conducted a systematic review and meta-analysis of randomized trials to determine the association between various blood purification techniques and all-cause mortality in humans with sepsis.

Data sources: We searched for relevant studies in MEDLINE, EMBASE, and the Cochrane Library database from January 1966 to May 2012.

Study selection: Inclusion required a diagnosis of sepsis and comparison of blood purification techniques including hemofiltration, hemoperfusion, plasma exchange, or hemodialysis with no blood purification (control group).

Data extraction: Two authors independently selected studies and extracted data. Summary statistics, risk ratios, and CIs were calculated using random-effects modeling. Study quality was assessed using Jadad score, and publication bias was assessed using funnel plots and Egger's statistic.

Data synthesis: Overall, blood purification decreased mortality compared with no blood purification (35.7% vs 50.1%; risk ratio, 0.69 [95% CI, 0.56-0.84]; p<0.001; 16 trials, n=827). However, these results were driven mainly by hemoperfusion (risk ratio, 0.63 [95% CI, 0.50-0.80]; p<0.001; 10 trials, n=557) and plasma exchange (risk ratio, 0.63 [95% CI, 0.42-0.96]; p=0.03; two trials, n=128). Pooling of all trials of blood purification for treatment of sepsis was no longer associated with lower mortality (risk ratio, 0.89 [95% CI, 0.71-1.13]; p=0.36; eight trials, n=457) after excluding trials using polymyxin B hemoperfusion.

Conclusions: Blood purification techniques including hemoperfusion, plasma exchange, and hemofiltration with hemoperfusion were associated with lower mortality in patients with sepsis. These results were mainly influenced by studies using polymyxin B hemoperfusion from Japan.

Figures

Figure 1

Quorum Chart of Study Cohort.

Figure 2

Risk Ratios (RRs) for Blood Purification versus Conventional Treatment. Pooled risk ratios are from a random effects model; CI indicates confidence interval; Size of the data markers indicates weight of the study.

Figure 3

Risk Ratios (RRs) for Different Modality of Blood Purification versus Conventional Treatment. Pooled risk ratios are from a random effects model; CI indicates confidence interval; Size of the data markers indicates weight of the study.

1. Different modalities of blood purification versus conventional treatment.

2. Different geographic region and hemoperfusion analysis of blood purification versus conventional treatment.

Figure 3

Risk Ratios (RRs) for Different Modality of Blood Purification versus Conventional Treatment. Pooled risk ratios are from a random effects model; CI indicates confidence interval; Size of the data markers indicates weight of the study.

1. Different modalities of blood purification versus conventional treatment.

2. Different geographic region and hemoperfusion analysis of blood purification versus conventional treatment.

Figure 4

Assessment of Publication Bias.

1. A funnel plot.

2. Egger’s test

Figure 4

Assessment of Publication Bias.

1. A funnel plot.

2. Egger’s test