Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials

Abstract

Objectives: This study aimed to conduct a comprehensive and updated systematic review with network meta-analysis (NMA) to assess the outcome benefits of various blood purification modalities for adult patients with severe infection or sepsis.

Data sources: We conducted a search of PubMed, MEDLINE, clinical trial registries, Cochrane Library, and Embase databases with no language restrictions.

Study selection: Only randomized controlled trials (RCTs) were selected.

Data extraction: The primary outcome was overall mortality. The secondary outcomes were the length of mechanical ventilation (MV) days and ICU stay, incidence of acute kidney injury (AKI), and kidney replacement therapy requirement.

Data synthesis: We included a total of 60 RCTs with 4,595 participants, comparing 16 blood purification modalities with 17 interventions. Polymyxin-B hemoperfusion (relative risk [RR]: 0.70; 95% CI, 0.57-0.86) and plasma exchange (RR: 0.61; 95% CI, 0.42-0.91) were associated with low mortality (very low and low certainty of evidence, respectively). Because of the presence of high clinical heterogeneity and intransitivity, the potential benefit of polymyxin-B hemoperfusion remained inconclusive. The analysis of secondary outcomes was limited by the scarcity of available studies. HA330 with high-volume continuous venovenous hemofiltration (CVVH), HA330, and standard-volume CVVH were associated with shorter ICU stay. HA330 with high-volume CVVH, HA330, and standard-volume CVVH were beneficial in reducing MV days. None of the interventions showed a significant reduction in the incidence of AKI or the need for kidney replacement therapy.

Conclusions: Our NMA suggests that plasma exchange and polymyxin-B hemoperfusion may provide potential benefits for adult patients with severe infection or sepsis/septic shock when compared with standard care alone, but most comparisons were based on low or very low certainty evidence. The therapeutic effect of polymyxin-B hemoperfusion remains uncertain. Further RCTs are required to identify the specific patient population that may benefit from extracorporeal blood purification.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. CRRT = continuous renal replacement therapy, RCT = randomized controlled trial.

Figure 2.

Network plot of eligible comparisons among interventions for mortality (A) and forest plot of eligible comparisons among interventions for mortality (B). The network plot depicts each intervention as a node, with lines indicating the direct comparison between different interventions. The size of the nodes and the width of the lines are weighted according to the number of participants within the intervention and the number of studies involved in the direct comparison, respectively. The number written on each line represents the number of studies involved in the direct comparison. CPFA = coupled plasma filtration and adsorption hemofiltration, CVVH = continuous venovenous hemofiltration, iHSA = immobilized human serum albumin, RR = relative risk, SCD = selective cytopheretic device.

Figure 3.

Forest plot of eligible comparisons among interventions for length of stay in ICU (A) and mechanical ventilation days (B). CPFA = coupled plasma filtration and adsorption hemofiltration, CVVH = continuous venovenous hemofiltration, iHSA = immobilized human serum albumin, MD = mean difference.

Figure 4.

Forest plot of eligible comparisons among interventions for acute kidney injury occurrence rates (A) and requirement of kidney replacement therapy (KRT) (B). PMX = polymyxin B hemoperfusion, RR = relative risk.