Clinical review: blood purification for sepsis

Thomas Rimmelé, John A Kellum, Thomas Rimmelé, John A Kellum

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.

Figures

Figure 1
Figure 1
The 'cytokinetic model'. Blood purification therapies increase the cytokine/chemokine concentration gradient from plasma to infected tissue by removing those inflammatory mediators from the blood compartment. Consequently, leukocyte trafficking is driven toward the nidus of infection, allowing the increase of local bacterial clearance. CPFA, coupled plasma filtration adsorption; HVHF, high-volume hemofiltration.
Figure 2
Figure 2
Cascade hemofiltration circuit.
Figure 3
Figure 3
Coupled plasma filtration adsorption circuit.
Figure 4
Figure 4
Electronic microscopy images of the internal surface of different filters.

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