Table 8.
Studies of Blood Purification in Necrotizing Soft Tissue Infection and Sepsis
| Author | Study design | Population | Control | Intervention | Adjustment | Death or survival (blood purification vs. none) |
|---|---|---|---|---|---|---|
| Meta-analyses and Systematic Reviews | ||||||
| Zhou et al. (2013) | Meta-analysis | Sepsis, severe sepsis, septic shock | N = 16 trials | All | N/A | All death: All (16 trials) RR: 0.69 (0.56–0.84), p < 0.001; hemoperfusion (10 trials) RR: 0.63 (0.50–0.80), p < 0.001; plasma exchange (2 trials) RR: 0.63 (0.42–0.96) p = 0.03; hemofiltration alone (4 trials) RR: 1.13 (0.75–1.71) p = 0.56; if exclude PMX RR: 0.89 (0.71–1.13 p = 0.36); HP with PMX RR: 0.57 (0.45–0.72) p < 0.001; without PMX RR: 0.98 (0.66–1.47) p = 0.44 |
| Rimmer et al. (2014) | Systematic review and meta-analysis | Sepsis and septic shock | N = 4 trials; 1 of adults, 2 of children, 1 of both | Plasmafiltration (Reeves et al); plasmapheresis (Busund et al) | N/A | All mortality: 0.63 (0.42–0.96) |
| Borthwick et al. (2013) | Systematic review | Sepsis | N = 3 trials | High volume hemofiltration | N/A | Unable to pool estimates because of heterogeneity; Boussekey (2008) reported 3/9 (33%) vs. 6/10 (60%), NS; Cole (2001) only reported hospital rates of 6/11 (54.5%) but is cross-over and no comparisons possible; Ghani (2006) no difference in 60-d survival or SOFA |
| Randomized Controlled Trials | ||||||
| Livigni et al. (2014) | Multicenter, open label, RCT | Septic shock | n = 96 | CPFA, n = 96 | N/A | Survival to discharge, NS |
| Cruz et al. (2009) EUPHAS Study Group | Multicenter, RCT | Abdominal septic shock | n = 30 | Hemoperfusion PMX B, n = 34 | N/A | 28-d death: 11/34 (32%) vs. 16/30 (53%); HR 0.43 (0.20–0.97); aHR 0.36 (0.16–0.80) |
| Payen et al. (2009) | Multicenter, open label, RCT | Severe sepsis | n = 40 | Hemofiltration, n = 40 | RCT | 14-d KM survival worse with HF: p = 0.10; 28-day survival: 46% vs. 56%, p = 0.49 |
| Vincent et al (2005) | Multicenter, open label, RCT | Severe sepsis or septic shock secondary to intra-abdominal infection | n = 19 | Hemoperfusion PMX B, n = 17 | N/A | 28-d survival: 5/17 (29%) vs. 5/18 (28%), p = 0.75 |
| Peng et al. (2005) | Single center, RCT | Severely burned with sepsis | n = 10 | n = 10, venovenous CRRT | N/A | NS, but no data described |
| Nakamura et al. (2004) | Single center, RCT | Severe sepsis | Controls, n = 50; healthy age matched, n = 70 | Hemoperfusion with PMX B, n = 70 | N/A | Not described |
| Nakamura et al. (2003) | Single center, RCT | Sepsis with MRSA | Controls, n = 10 | Hemoperfusion using PMX B, n = 10 | N/A | In-hospital survival: 8/10 (50%) vs. 2/10(20%), p = 0.007 |
| Reinhart et al (2004) Easy Study Group | Single center, RCT | Severe sepsis/septic shock | n = 76 | LPS adsorption, n = 67 | RCT | 28-d survival: 71.2% vs. 74.3%, p = 0.71 |
| Nakamura et al. (2003) | Single center, RCT | Sepsis with MRSA | Controls, n = 10 | Hemoperfusion with PMX B, n = 15 | N/A | In-hospital survival 53% vs. 20%; RR 0.58 (0.31–1.09) |
| Nakamura et al. (2002) | Single center, RCT | Sepsis with MRSA | HD without sepsis, n = 7; age matched controls, n = 12 | HD with sepsis, hemoperfusion with PMX B, n = 7 | N/A | In-hospital survival: 5/7 (71%) vs. 1/7 (14%), p = 0.03 |
| Cole et al. (2002) | Single center, RCT | Severe sepsis, septic shock | Controls, n = 12 | Continuous venovenous hemofiltration (CVVH), n = 12 | N/A | In-hospital survival: 8/12 vs. 8/12, p = 1.0 |
| Busund et al. (2002) | Single center, RCT | Severe sepsis, septic shock | n = 52 | Plasmapheresis (PE), n = 52 | N/A | 28-d survival: 33.3% vs. 53.8%, p = 0.05; OR 1.46 (1.03–2.12), p = 0.03; aOR 0.41 (0.15–1.09) p = 0.07 |
| Nemoto et al. (2001) | Single center, RCT | Sepsis, severe sepsis, septic shock | Controls, n = 44 | Hemoperfusion with PMX B, n = 54 | N/A | KM 28-d survival: 22/54 (41%) vs. 5/44 (11%), p = 0.002 |
| Zu et al. (2015) | Single center, RCT | Burns with severe sepsis | n = 97 | CVVHDF; n = 98 | N/A | 28-d survival: 80.6% vs. 72.2%, p < 0.05 |
| Reeves et al. (1999) | Multicenter RCT | Sepsis syndrome | n = 18; 13 adults, 3 children | n = 14, continuous plasmapheresis (PE); 9 adults, 5 children | RCT | 14-d survival: 8/14 (57%) vs. 8/16 (50%), p = 0.73; aOR 1.78 (0.20–18.1) |
| Observational Studies | ||||||
| Yaroustovsky et al. (2015) | Prospective | Severe sepsis | n = 20 | LPS+CPFA, n = 20 | No | 28-d survival 65 vs. 35%, p = 0.11 |
| Yaroustovsky et al. (2014) | Retrospective | Severe sepsis | Historical, n = 30 | LPS+HD, n = 26 | No | 28-d survival: 65.5% vs. 33.3%, p = 0.03 |
| Sakamoto et al. (2010) | Prospective | Septic shock | None | DHP-PMS, n = 26; CVVHDF-PMMA, n = 28; CVVHD-PAN, n = 26 | No | All survival: PMMA-CVVHD, 80% vs. other, 45%, p = 0.0196 |
| Huang et al. (2010) | Prospective | Severe sepsis, septic shock | n = 20 | Hemoperfusion using neutral porous resin, n = 24 | RCT | 28-d survival: 13/24 (44.2%) vs. 9/20 (25%), p = 0.47 |
| Asanuma et al. (2004) | Retrospective | Severe sepsis | None | PMX B, n = 17; CHF/CHDF, n = 15; PE+CHDF, n = 3 | No | All survival: 57% vs. 42%, NS (no statistics performed) |
| Nakamura et al. (2004) | Prospective, quasi-randomized | Severe sepsis | Controls, n = 10; healthy controls, n = 20 | Hemoperfusion with PMX B, n = 15 | RCT | In-hospital survival: 80% vs. 40%, p < 0.05 |
| Ronco et al. (2002) | Prospective, crossover | Septic shock | None | PFAD or CVVHDF (10 h treatments), n = 10 | None | Not studied |
| Schmidt et al. (2000) | Prospective | Severe sepsis, septic shock | Controls, n = 24 | CVVHF with plasma exchange, n = 19 | None | All survival: 8/19 (42.1%) vs. 11/24 (45.8%), NS; single organ failure: 4/4 (100%) vs. 3/4 (75%), NS; double organ failure: 5/6 (83%) vs. 7/12 (58%), p < 0.001 |
| Tani et al. (1998) | Prospective | Septic shock | n = 33 | Hemoperfusion with PMX B, n = 37 | None | In-hospitaI survival: 20/37 (54%) vs. 12/33 (36.4%), p < 0.05; > 4 failed organs: 7/21 (33%) vs. 1/13(8%), p < 0.01 |
RR = relative risk; PMX = polymixin; HP = hemoperfusion; SOFA = Sequential Organ Failure Assessment; RCT = randomized controlled trial; HR = hazard ratio; aHR = adjusted hazard ratio; KM = Kaplan Meier; HF = hemofiltration; CCRT = ________; MRSA = methicillin resistant Staphylococcus aureus; HD = hemodialysis; CVVH = continuous venovenous hemofiltration; CVVHDF = continuous venovenous hemodiafiltration; PE = plasmapheresis; LPS = lipopolysaccharide; CPFA = coupled plasma filtration and adsorption; DHP = direct hemoperfusion; PMX = polymyxin B; PMMA = polymethylmethacrylate; PAN = polyacrylonitrile; CHF = continuous hemofiltration; CHDF = continuous hemodiafiltration.