Early Classic Hemofiltration Exhibits No Benefits in Severe Acute Pancreatitis With Early Organ Failure: A Retrospective Case-Matched Study

High-volume hemofiltration reduces short-term mortality with no influence on the incidence of MODS, hospital stay, and hospitalization cost in patients with severe-acute pancreatitis: A meta-analysis

This study aimed to investigate the efficiency, safety and cost-efficiency of blood purification (BP) in treating patients with severe-acute pancreatitis (SAP). A literature search was conducted using PubMed, OVID, International Clinical Trials Register (ICTRP), and Cochrane Central Register of Controlled Trials (CENTRAL). A total of 11 prospective studies and 6 retrospective studies, which reported the mortality of 1279 SAP patients, were included for analysis. Decreased short-term mortality and incidence rate of infection were observed in the high-volume hemofiltration (HVHF) group, but not in patients treated with other types of BP. There was no significant difference in the incidence of multiple-organ dysfunction (MODS), duration of hospital stay, or cost of hospitalization between the BP and non-BP groups. The starting time point, substitution fluid flow rate, filter membrane type, hemofilter change interval, anticoagulation, and sustaining times of BP varied across studies. In conclusion, HVHF may reduce the short-term mortality (<4 weeks), not long-term mortality, of SAP patients by decreasing the incidence of infection, while other types of BP did not show a significant beneficial effect. Neither HVHF nor other BP patterns affect the duration of hospital stay, cost of hospitalization, or incidence of MODS in SAP patients.

Continuous Hemofiltration Reduces Mortality in Severe Acute Pancreatitis: A Meta-Analysis

Background

Severe acute pancreatitis (SAP) is a deadly condition, with a mortality rate ranging from 15% to 30%. Recently, blood purification therapy has been adopted in administrating SAP patients. The present study aimed at evaluating the effect of continuous hemofiltration therapy for SAP.

Methods

A systematic search of Cochrane Library, PubMed, and Embase was carried out until October 1^st, 2019. Prospective studies comparing outcomes for SAP patients between continuous hemofiltration and standard therapy were enrolled.

Results

Continuous hemofiltration therapy was associated with lower level of PACHE II score (MD = −1.49; 95% CI: −2.69 to −0.29, P=0.02), CRP (MD = −1.56 mg/L; 95% CI: −2.64 to −0.47, P=0.005), Cr (MD = −3.57 umol/L; 95% CI: −5.50 to −1.65, P=0.003), and Bun (MD = −3.63 mmol/L; 95% CI: −6.07 to −1.20, P=0.003) at 72 h after onset of treatment. Continuous hemofiltration therapy was associated with shorter length of abdominal pain relief time (MD = −1.82 hours; 95% CI: −2.93 to −0.71, P=0.001), lower surgery rate (OR = 0.15; 95% CI: 0.03 to 0.78, P=0.02), and mortality rate (OR = 0.54; 95% CI: 0.37 to 0.77, P=0.0007).

Conclusions

continuous hemofiltration therapy could effectively alleviate SAP as early as 72 hours after onset of treatment, lowering the level of Bun, Cr, CRP, and APACHE II scores. Continuous hemofiltration therapy could confer SAP patients with lower mortality rates.

Hemofiltration in Patients with Severe Acute Pancreatitis (Review)

Questions regarding the application of extracorporeal detoxification to patients with severe acute pancreatitis have been considered. Hemodialysis, the historically first method of extracorporeal detoxification for such patients, has been also described in the review. Appropriateness of using renal replacement therapy methods and among them continued renal replacement therapy has been shown. Hemofiltration and hemodiafiltration technologies are described in detail including different modes of their application and the possibility of using various types of filters. Available data on hemofiltration for patients with severe acute pancreatitis have been analyzed. Great attention is paid to the unsolved aspects of hemofiltration in severe acute pancreatitis such as determining renal and extrarenal indices; time of starting hemofiltration; selection of volume replacement modes and a buffer system; procedure duration; anticoagulation measures, defining criteria to assess the adequacy of hemofiltration, state severity, and organ dysfunction degree. Further multicenter investigations are necessary to be able to assess the efficacy of the hemofiltration procedures on the basis of the thoroughly worked out and pathogenically grounded protocol using adequate control methods taking into consideration endogenic intoxication phases and intensity of the multiple organ failure syndrome.

Continuous veno-venous hemofiltration for severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis is associated with high rates of mortality and life-threatening complications. Continuous veno-venous hemofiltration (CVVH) has been used in some centers to reduce mortality and avoid local or systemic complications, however its efficiency and safety is uncertain.

OBJECTIVES

To assess the benefits and harms of CVVH in patients suffering from severe acute pancreatitis; to compare the effects of different CVVH techniques; and to evaluate the optimal time for delivery of CVVH.

SEARCH METHODS

We searched the Cochrane Library (2019, Issue 8), MEDLINE (1946 to 13 September 2019), Embase (1974 to 13 September 2019), and Science Citation Index Expanded (1982 to 13 September 2019).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared CVVH versus no CVVH in participants with severe acute pancreatitis. We also included RCTs that compared different types of CVVH and different schedules for CVVH in participants with severe acute pancreatitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included two studies, involving a total of 94 participants, in the review.Continuous veno-venous hemofiltration versus no interventionWe included one study in which 64 participants with severe acute pancreatitis were randomized to undergo CVVH (32 participants) or no intervention (32 participants). There were no deaths in either group (very low-quality evidence). Adverse events, length of stay in the intensive care unit (ICU), length of hospital stay, total hospital cost, and quality of life were not reported in the study.One type of continuous veno-venous hemofiltration versus a different type of continuous veno-venous hemofiltrationWe included one study in which 30 participants with severe acute pancreatitis were randomized to undergo high-volume CVVH (15 participants) or standard CVVH (15 participants). High-volume CVVH may lead to little or no difference in in-hospital mortality rates (20.0% in the high-volume CVVH group versus 33.3% in the standard CVVH group; risk ratio (RR) 0.60, 95% confidence interval (CI) 0.17 to 2.07; 30 participants; 1 study; low-quality evidence). We are uncertain whether high-volume hemofiltration reduces rates of adverse events (13.3% in both groups; RR 1.00, 95% CI 0.16 to 6.20; 30 participants; 1 study; very low-quality evidence). Length of ICU stay, length of hospital stay, total hospital cost, and quality of life were not reported in the study.

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low or low. For both comparisons addressed in this review, data are sparse. It is unclear whether CVVH has any effect on mortality or complications in patients with severe acute pancreatitis. It is also unclear whether high-volume CVVH is superior, equivalent or inferior to standard CVVH in patients with severe acute pancreatitis.

Continuous blood purification for severe acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

The incidence of acute pancreatitis (AP) is rising around the world, thus further increasing the burden on healthcare services. Approximately 20% of AP will develop severe acute pancreatitis (SAP) with persistent organ failure (>48 h), which is the leading cause of high mortality. To date, there is no specific drug in treating SAP, and the main treatment is still based on supportive care. However, some clinical control studies regarding the superiority of continuous blood purification (CBP) has been published recently. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy of CBP in SAP treatment.

METHODS

Four databases (Medline, SinoMed, EMBASE, and Cochrane Library) were searched for eligible studies from 1980 to 2018 containing a total of 4 randomized controlled trials and 8 prospective studies.

RESULTS

After the analysis of data amenable to polling, significant advantages were found in favor of the CBP approach in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score (WMD = -3.00,95%CI = -4.65 to -1.35), serum amylase (WMD = -237.14, 95% CI = -292.77 to 181.31), serum creatinine (WMD = -80.54,95%CI = 160.17 to -0.92), length of stay in the ICU (WMD = -7.15,95%CI = -9.88 to -4.43), and mortality (OR = 0.60, 95%CI = 0.38-0.94). No marked differences were found in terms of C-reactive protein (CRP), alamine aminotransferase (ALT) and length of hospital stay (LOS).

CONCLUSION

Compared with conventional treatment, CBP remedy evidently improved clinical outcomes, including reduced incidence organ failure, decreased serum amylase, APACHE II score, length of stay in the ICU and lower mortality rate, leading us to conclude that it is a safer treatment option for SAP. Furthermore, relevant multicenter RCTs are required to prove these findings.