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Tegl V, Horak J, Nalos L, Horakova M, Stengl M, Matejovic M, Benes J. Ineffectiveness of hemoadsorption in large animals with abdominal sepsis: a randomized controlled porcine study. Intensive Care Med Exp 2024; 12:38. [PMID: 38635084 PMCID: PMC11026308 DOI: 10.1186/s40635-024-00622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES The use of hemoadsorption (HA) has become popular in the treatment of vasoplegic states associated with massive cytokine release, including septic shock. However, this approach does not seem to be based on robust evidence, and it does not follow international guidelines. To understand the pathophysiological rationale and timing of HA, we conducted a large animal septic shock experiment. DESIGN Prospective randomized large-animal peritoneal septic shock experiment. SETTING Laboratory investigation. SUBJECTS Twenty-six anesthetized, mechanically ventilated, and instrumented pigs randomly assigned into (1) sham-operated group with HA (SHAM, n = 5); (2) sepsis animals without HA (SEPSIS, n = 5); (3) sepsis group with HA at norepinephrine initiation (EARLY, n = 8); and (4) sepsis group with HA initiated at norepinephrine rate reaching 0.5 μg/kg/min (LATE, n = 8). INTERVENTIONS Peritoneal sepsis was induced by cultivated autologous feces inoculation. A CytoSorb cartridge (200 g) with a blood flow rate of 200 mL/min and heparin anticoagulation was used to perform HA. The animals received sedation and intensive organ support up to 48 h or until they experienced cardiovascular collapse. MEASUREMENTS AND MAIN RESULTS Systemic hemodynamics, multiple-organ functions, and immune-inflammatory response were measured at predefined periods. The HA treatment was not associated with any measurable benefit in terms of systemic hemodynamics and organ support. The systemic inflammatory markers were unaffected by any of the treatment timings. In contrast, the HA resulted in higher vasopressor load and decreased 36-h survival (5 animals in SHAM (100%), 4 (80%) in SEPSIS, 4 (57%) in EARLY, and 2 (25%) in LATE; p = 0.041). The HA exposure in healthy animals was associated with hemodynamic deterioration, systemic inflammatory response, and cytopenia. CONCLUSIONS In this large-animal-controlled fulminant sepsis study, the HA was unable to counteract the disease progression in the early or advanced septic shock phase. However, findings from the HA-exposed sham animals suggest potential safety concerns.
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Affiliation(s)
- Vaclav Tegl
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic
| | - Jan Horak
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Lukas Nalos
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Laboratory of Experimental Cardiology, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Michala Horakova
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic
| | - Milan Stengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Laboratory of Experimental Cardiology, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martin Matejovic
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jan Benes
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic.
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic.
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Becker S, Lang H, Vollmer Barbosa C, Tian Z, Melk A, Schmidt BMW. Efficacy of CytoSorb®: a systematic review and meta-analysis. Crit Care 2023; 27:215. [PMID: 37259160 PMCID: PMC10230475 DOI: 10.1186/s13054-023-04492-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/15/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Cytokine adsorption using the CytoSorb® adsorber has been proposed in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or recovery after cardiac arrest. The aim of this analysis is to provide evidence for the efficacy of the CytoSorb® adsorber with regard to mortality in various settings. METHODS We searched PubMed, Cochrane Library database and the database provided by Cytosorbents™ (01.1.2010-29.5.2022). We considered randomized controlled trials and observational studies with control groups. The longest reported mortality was defined as the primary endpoint. We computed risk ratios and 95%-confidence intervals and used DerSimonian and Lairds random effects model. We analysed all studies combined and divided them into the subgroups: sepsis, cardiopulmonary bypass surgery (CPB), other severe illness, SARS-CoV-2 infection and recovery from cardiac arrest. The meta-analysis was registered in advance (PROSPERO: CRD42022290334). RESULTS Of an initial 1295 publications, 34 studies were found eligible, including 1297 patients treated with CytoSorb® and 1314 controls. Cytosorb® intervention did not lower mortality (RR [95%-CI]: all studies 1.07 [0.88; 1.31], sepsis 0.98 [0.74; 1.31], CPB surgery 0.91 [0.64; 1.29], severe illness 0.95 [0.59; 1.55], SARS-CoV-2 1.58 [0.50; 4.94]). In patients with cardiac arrest, we found a significant survival advantage of the untreated controls (1.22 [1.02; 1.46]). We did not find significant differences in ICU length of stay, lactate levels, or IL-6 levels after treatment. Of the eligible 34 studies only 12 were randomized controlled trials. All observational studies showed moderate to serious risk of bias. INTERPRETATION To date, there is no evidence for a positive effect of the CytoSorb® adsorber on mortality across a variety of diagnoses that justifies its widespread use in intensive care medicine.
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Affiliation(s)
- Sören Becker
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Hannah Lang
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Clara Vollmer Barbosa
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Zhejia Tian
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Akalay S, Hosgood SA. How to Best Protect Kidneys for Transplantation-Mechanistic Target. J Clin Med 2023; 12:jcm12051787. [PMID: 36902572 PMCID: PMC10003664 DOI: 10.3390/jcm12051787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
The increasing number of patients on the kidney transplant waiting list underlines the need to expand the donor pool and improve kidney graft utilization. By protecting kidney grafts adequately from the initial ischemic and subsequent reperfusion injury occurring during transplantation, both the number and quality of kidney grafts could be improved. The last few years have seen the emergence of many new technologies to abrogate ischemia-reperfusion (I/R) injury, including dynamic organ preservation through machine perfusion and organ reconditioning therapies. Although machine perfusion is gradually making the transition to clinical practice, reconditioning therapies have not yet progressed from the experimental setting, pointing towards a translational gap. In this review, we discuss the current knowledge on the biological processes implicated in I/R injury and explore the strategies and interventions that are being proposed to either prevent I/R injury, treat its deleterious consequences, or support the reparative response of the kidney. Prospects to improve the clinical translation of these therapies are discussed with a particular focus on the need to address multiple aspects of I/R injury to achieve robust and long-lasting protective effects on the kidney graft.
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Affiliation(s)
- Sara Akalay
- Department of Development and Regeneration, Laboratory of Pediatric Nephrology, KU Leuven, 3000 Leuven, Belgium
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence:
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Ricci Z, Romagnoli S, Reis T, Bellomo R, Ronco C. Hemoperfusion in the intensive care unit. Intensive Care Med 2022; 48:1397-1408. [PMID: 35984473 PMCID: PMC9389493 DOI: 10.1007/s00134-022-06810-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
Multiple organ failure following a septic event derives from immune dysregulation. Many of the mediators of this process are humoral factors (cytokines), which could theoretically be cleared by direct adsorption through a process called hemoperfusion. Hemoperfusion through devices, which bind specific molecules like endotoxin or theoretically provide non-specific adsorption of pro-inflammatory mediators has been attempted and studied for several decades with variable results. More recently, technological evolution has led to the increasing application of adsorption due to more biocompatible and possibly more efficient biomaterials. As a result, new indications are developing in this field, and novel tools are available for clinical use. This narrative review will describe current knowledge regarding technical concepts, safety, and clinical results of hemoperfusion. Finally, it will focus on the most recent literature regarding adsorption applied in critically ill patients and their indications, including recent randomized controlled trials and future areas of investigation. Clinical trials for the assessment of efficacy of hemoperfusion in septic patients should apply the explanatory approach. This includes a highly selected homogenous patient population. Enrichment criteria such as applying genetic signature and molecular biomarkers allows the identification of subphenotypes of patients. The intervention must be delivered by a multidisciplinary team of trained personnel. The aim is to maximize the signals for efficacy and safety. In a homogenous cohort, confounding uncontrolled variables are less likely to exist. Trials with highly selected populations have a high internal validity but poor generalizability. The parallel design described in the figure is robust and usually is required by regulatory agencies for the approval of a new treatment. Allocation concealment and randomization are key to minimize bias such as confirmation bias, observer bias. The intervention should be delivered following a strict protocol. Deviations from the protocol might negatively influence the potential effects of the therapies. Surrogates such as cytokine measurement are adequate primary outcomes in phase 3 trials with small sample size because there is a higher likelihood of finding positive results concerning surrogate markers than in respect with clinical outcomes. Once a trial shows positive results concerning surrogate markers, a rationale for another phase 3 trial exploring clinical outcomes is built, justifying the allocation of financial sources to the intended trial.
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Affiliation(s)
- Zaccaria Ricci
- Pediatric Intensive Care Unit, Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Thiago Reis
- D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
- Department of Kidney Transplantation, Clínica de Doenças Renais de Brasília, Brasília, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Vicenza, Italy
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