Polymyxin B hemoperfusion: a mechanistic perspective

Highly efficient strategy of lipopolysaccharide (LPS) decontamination from rHBsAg: synergistic effect of enhanced magnetic nanoparticles (MNPs) as an LPS affinity adsorbent (LAA) and surfactant as a dissociation factor

The interaction of lipopolysaccharide with a recombinant protein is a serious bottleneck, particularly in the purification step of bioprocessing. Recombinant hepatitis B surface antigen (rHBsAg), the active ingredient of the hepatitis B vaccine, is probably contaminated by extrinsic LPS like other biopharmaceuticals. This research intends to eliminate LPS from its mixture with rHBsAg efficiently. Immobilized polymyxin B on magnetic nanoparticles (PMB-MNPs) was synthesized and implemented as an enhanced LPS affinity adsorbent (LAA). The 20-80 EU/dose binary samples with and without surfactant were applied to PMB-MNPs. Formerly, dynamic light scattering (DLS) and transmission electron microscopy (TEM) were examined on the samples to qualitatively show the dissociation effect of the surfactant. Considering the high potential interaction of LPS with HBsAg, the dissociation effects of 0.5 and 1.5% Tween 20 on the binary samples were assessed using immunoaffinity chromatography (IAC) as a quantification tool. The dissociation effect of Tween 20 substantially diminished the interaction, leading to a proportional increase of free LPS up to 66%. The synergetic effect of Tween 20 and privileged LAA was highly effective in eliminating more than 80% of LPS with a remarkable LPS clearance factor of 5.8 and a substantial protein recovery rate of 97%.

Evolving Paradigms in Sepsis Management: A Narrative Review

Sepsis, a condition characterized by life-threatening organ dysfunction due to a dysregulated host response to infection, significantly impacts global health, with mortality rates varying widely across regions. Traditional therapeutic strategies that target hyperinflammation and immunosuppression have largely failed to improve outcomes, underscoring the need for innovative approaches. This review examines the development of therapeutic agents for sepsis, with a focus on clinical trials addressing hyperinflammation and immunosuppression. It highlights the frequent failures of these trials, explores the underlying reasons, and outlines current research efforts aimed at bridging the gap between theoretical advancements and clinical applications. Although personalized medicine and phenotypic categorization present promising directions, this review emphasizes the importance of understanding the complex pathogenesis of sepsis and developing targeted, effective therapies to enhance patient outcomes. By addressing the multifaceted nature of sepsis, future research can pave the way for more precise and individualized treatment strategies, ultimately improving the management and prognosis of sepsis patients.

Effects of Early Initiation of Polymyxin B Hemoperfusion Therapy in Patients with Cancer with Refractory Septic Shock

Background: We aimed to analyze the correlation between in-hospital mortality and hemodynamic changes, using polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) initiation time in patients with cancer with refractory septic shock. Methods: Forty-six patients with cancer who received PMX-DHP for refractory septic shock were retrospectively analyzed and classified into early (≤3 h between refractory septic shock and PMX-DHP; n = 17) and late (>3 h; n = 29) initiation groups. The vasopressor inotropic score (VIS), sequential organ failure assessment (SOFA) score, and lactate clearance before and 24 h post-PMX-DHP were compared. Results: Overall, 52.17% died from multiple organ dysfunction, with a lower mortality rate in the early initiation group. The VIS and SOFA score decreased in both groups, but the magnitude of decrease was not significant. Lactate clearance improved in both groups, with greater improvement in the early initiation group. Univariable analysis identified associations of in-hospital mortality with early initiation, ΔC-reactive protein, lactate clearance, ΔSOFA score, and ΔVIS. Multivariable analysis demonstrated associations of in-hospital mortality risk with ΔSOFA score and early PMX-DHP initiation. Overall survival was higher in the early initiation group. Early initiation of PMX-DHP in patients with cancer with refractory septic shock reduced in-hospital mortality and improved lactate clearance.

Blood Purification in Patients with Sepsis Associated with Acute Kidney Injury: A Narrative Review

Sepsis leads to organ dysfunction. Acute kidney injury, a common type of organ dysfunction, is associated with a high mortality rate in patients with sepsis. Kidney replacement therapy can correct the metabolic, electrolyte, and fluid imbalances caused by acute kidney injury. While this therapy can improve outcomes, evidence of its beneficial effects is lacking. Herein, we review the indications for blood purification therapy, including kidney replacement therapy, and the current knowledge regarding acute kidney injury in terms of renal and non-renal indications. While renal indications have been well-documented, indications for blood purification therapy in sepsis (non-renal indications) remain controversial. Excessive inflammation is an important factor in the development of sepsis; blood purification therapy has been shown to reduce inflammatory mediators and improve hemodynamic instability. Given the pathophysiology of sepsis, blood purification therapy may decrease mortality rates in these patients. Further trials are needed in order to establish the effectiveness of blood purification therapy for sepsis.

Blood purification for treatment of non-liquefied multiple liver abscesses and improvement of T-cell function: A case report

BACKGROUND

Non-liquefied multiple liver abscesses (NMLA) can induce sepsis, septic shock, sepsis-associated kidney injury (SA-AKI), and multiple organ failure. The inability to perform ultrasound-guided puncture and drainage to eradicate the primary disease may allow for the persistence of bacterial endotoxins and endogenous cytokines, exacerbating organ damage, and potentially causing immunosuppression and T-cell exhaustion. Therefore, the search for additional effective treatments that complement antibiotic therapy is of great importance.

CASE SUMMARY

A 45-year-old critically ill female patient presented to our hospital's intensive care unit with intermittent vomiting, diarrhea, and decreased urine output. The patient exhibited a temperature of 37.8 °C. Based on the results of liver ultrasonography, laboratory tests, fever, and oliguria, the patient was diagnosed with NMLA, sepsis, SA-AKI, and immunosuppression. We administered antibiotic therapy, entire care, continuous renal replacement therapy (CRRT) with an M100 hemofilter, and hemoperfusion (HP) with an HA380 hemofilter. The aforementioned treatment resulted in a substantial reduction in disease severity scores and a decrease in the extent of infection and inflammatory factors. In addition, the treatment stimulated the expansion of the cluster of differentiation 8+ (CD8+) T-cells and led to the complete recovery of renal function. The patient was discharged from the hospital. During the follow-up period of 28 d, she recovered successfully.

CONCLUSION

Based on the entire therapeutic regimen, the early combination of CRRT and HP therapy may control sepsis caused by NMLA and help control infections, reduce inflammatory responses, and improve CD8+ T-cell immune function.

Endotoxin activity trend and multi-organ dysfunction in critically ill patients with septic shock, who received Polymyxin-B hemadsorption: A multicenter, prospective, observational study

BACKGROUND

The baseline endotoxin activity (EAT0) may predict the outcome of critically ill septic patients who receive Polymyxin-B hemadsorption (PMX-HA), however, the clinical implications of specific EA trends remain unknown.

METHODS

Subgroup analysis of the prospective, multicenter, observational study EUPHAS2. We included 50 critically ill patients with septic shock and EAT0 ≥ 0.6, who received PMX-HA. The primary outcome of the study was the EA and SOFA score progression from T0 to 120 h afterwards (T120). Secondary outcomes included the EA and SOFA score progression in whom had EA at 48 h (EAT48) < 0.6 (EA responders, EA-R) versus who had not (EA non-responders, EA-NR).

RESULTS

Septic shock was mainly caused by 27 abdominal (54%) and 17 pulmonary (34%) infections, predominantly due to Gram negative bacteria (39 patients, 78%). The SAPS II score was 67.5 [52.8-82.3] and predicted a mortality rate of 75%. Between T0 and T120, the EA decreased (p < 0.001), while the SOFA score and the Inotropic Score (IS) improved (p < 0.001). In comparison with EA-NR (18 patients, 47%), the EA-R group (23 patients, 53%) showed faster IS improvement and lower requirement of continuous renal replacement therapy (CRRT) during the ICU stay. Overall hospital mortality occurred in 18 patients (36%).

CONCLUSIONS

In critically ill patients with septic shock and EAT0 ≥ 0.6 who received PMX-HA, EA decreased and SOFA score improved over 120 h. In whom high EA resolved within 48 h, IS improvement was faster and CRRT requirement was lower compared with patients with EAT48 ≥ 0.6.

Targeted therapy using polymyxin B hemadsorption in patients with sepsis: a post-hoc analysis of the JSEPTIC-DIC study and the EUPHRATES trial

BACKGROUND

Polymyxin B hemadsorption (PMX-HA) reduces blood endotoxin levels, but characteristics of patients with sepsis likely to benefit from PMX-HA are not well known. We sought to identify patient subgroups likely to benefit from PMX-HA.

METHODS

We retrospectively identified 1911 patients with sepsis from a retrospective observational study in Japan (the JSEPTIC-DIC study) and 286 patients with endotoxemic septic shock from a randomized controlled trial in North America that restricted patients to those with high endotoxin activity (the EUPHRATES trial). We applied the machine learning-based causal forest model to the JSEPTIC-DIC cohort to investigate heterogeneity in treatment effects of PMX-HA on 28-day survival after adjusting for potential confounders and ascertain the best criteria for PMX-HA use. The derived criteria for targeted therapy by PMX-HA were validated using the EUPHRATES trial cohort.

RESULTS

The causal forest model revealed heterogeneity in treatment effects of PMX-HA. Since patients having higher treatment effects were more likely to have severe coagulopathy and hyperlactatemia, we identified the potential treatment targets of PMX-HA as patients with PT-INR > 1.4 or lactate > 3 mmol/L. In the EUPHRATES trial cohort, PMX-HA use on the targeted subpopulation (75% of all patients) was significantly associated with higher 28-day survival (PMX-HA vs. control, 68% vs. 52%; treatment effect of PMX-HA, + 16% [95% CI + 2.2% to + 30%], p = 0.02).

CONCLUSIONS

Abnormal coagulation and hyperlactatemia in septic patients with high endotoxin activity appear to be helpful to identify patients who may benefit most from PMX-HA. Our findings will inform enrollment criteria for future interventional trials targeting patients with coagulopathy and hyperlactatemia.

Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion

Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.

Cytokine modulation in abdominal septic shock via the crucial role of IL-6 signaling in endothelial dysfunction

Background

Early recovery from shock improves prognosis in septic shock patients. We determined whether cytokine modulation by Continuous Renal Replacement Therapy (CRRT) following acute care surgery resulted in stable hemodynamics in them. To investigate our hypothesis, we measured proinflammatory cytokines IL-6, IL-1ra and the coagulation cascade activator plasminogen activator inhibitor-1 (PAI-1) following CRRT with polymyxin B immobilized fiber (PMX-DHP) which has been utilized as an adjuvant treatment option for patients with severe septic shock.

Methods

66 septic shock patients requiring 2 h direct hemoperfusion therapy PMX-DHP were included. 36 patients of them also received continuous hemodiafiltration (CHDF) after performing PMX-DHP. Circulatory dynamics and levels of inflammatory mediators, namely IL-6, IL-1ra, and PAI-1 were assessed before, immediately after, and 24 h initiation of PMX-DHP.

Results

Mean Arterial Pressure (MAP) rose intentionally by PMX-DHP just after enforcement 24 h later (p &lt; 0.01). Levels of IL-6, IL-1ra, and PAI-1 significantly decreased after PMX-DHP (p &lt; 0.05) and this trend was observed up to 24 h post initiation of PMX-DHP (p &lt; 0.05). IL-6 modulation by PMX-DHP was enhanced with using CHDF and there was a significant correlation between IL-6 and MAP (p &lt; 0.0001). In addition, levels of Il-6 and PAI-1 showed a significant correlation.

Conclusion

Our data showed employing CRRT as cytokine modulators could be an additional therapeutic strategy to improve septic shock outcomes via the crucial role of IL-6 signaling in endothelial dysfunction.

Cost-effectiveness of polymyxin B hemoperfusion for septic shock: an observational study using a Japanese nationwide administrative database

BACKGROUND

Polymyxin B hemoperfusion (PMX) removes endotoxin from septic shock patients. Although the treatment has been clinically used for more than 20 years, its cost-effectiveness has not been evaluated in detail.

METHODS

This study used the Japanese diagnosis procedure combination (DPC) administrative database from April 2018 to March 2021. We selected adult patients with a primary diagnosis of sepsis and the SOFA score at the sepsis diagnosis was between 7 and 12. The patients were divided into the PMX group that received PMX treatment and the control group that did not receive PMX. After adjusting the patient background by propensity score matching, we calculated the incremental cost-effectiveness ratio (ICER) by determining the difference in quality-adjusted life-year (QALY) and medical cost between the PMX and the control groups.

RESULTS

Nineteen thousand two hundred eighty-three patients were included in the study. Among them, 1492 patients received PMX treatment, and 17,791 did not. As a result of 1:3 propensity score matching, 965 patients in the PMX group and 2895 patients in the control group were selected and analyzed. Twenty-eight-day mortality and hospital mortality were significantly lower in the PMX group. The average medical cost per patient of the PMX group was 31,418 ± 21,144 Euro and that of the control group was 24,483 ± 21,762 Euro, with a difference of 6935 Euro. Life expectancy, life year-gained (LYG), and the QALY were 1.70, 0.86, and 0.60 years longer in the PMX group, respectively. The ICER was calculated to be 11,592 Euro/year, which was lower than the reported willingness-to-pay threshold of 38,462 Euro/year.

CONCLUSION

Polymyxin B hemoperfusion was shown to be an acceptable treatment in terms of the medical economy.

Potential survival benefit and early recovery from organ dysfunction with polymyxin B hemoperfusion: perspectives from a real-world big data analysis and the supporting mechanisms of action

Background

Endotoxin (ET) removal therapy with polymyxin B-immobilized fiber column hemoperfusion (PMX-HP) has been used for the treatment of septic shock. Some observational studies reported clinical benefits, particularly in specific subgroups of patients. However, larger randomized controlled trial results have been disappointing.

Main body

The four studies that revealed the survival benefit of PMX-HP were based on the Japanese Diagnosis Procedure Combination (DPC) national inpatient database (J-DPC study). Nevertheless, one J-DPC study and a randomized controlled trial (RCT) conducted in France evaluated PMX-HP in patients with abdominal septic shock and did not report a significant survival benefit. In both studies, the severity of illness was too low to find substantial significant differences in mortality. The results of the J-DPC studies further suggest that some subpopulations of patients could benefit from PMX-HP. Based on these results, this review revisited prior RCTs and other large-scale studies on PMX-HP. In addition, four J-DPC studies and one large-scale study reported a survival benefit with PMX-HP. A secondary analysis of the EUPHRATES trial, the most recent double-blinded RCT of PMX-HP conducted in North America, suggested a survival benefit in patients with high levels of endotoxemia. In the J-DPC studies and the EUPHRATES trial, ventilator-free days, vasoactive drug-free days, and renal replacement-free days were significantly improved in the PMX-HP groups. These findings suggest that PMX-HP can contribute to early recovery from organ dysfunction. The reduction of supportive care likely provides important health and economic benefits for managing patients with septic shock. Finally, the blood levels of mediators or biomarkers related to respiratory, cardiovascular, and renal dysfunction have been reported to be normalized with PMX-HP.

Conclusions

These results support the biological rationale for the improvement in organ dysfunction observed in the J-DPC studies and other large-scale studies, including the EUPHRATES trial. Real-world evidence from large data sets suggests an appropriate patient population that are likely to benefit from the utility of PMX-HP for septic shock.

Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series

OBJECTIVES

To evaluate the use of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) as adjunctive therapy during pediatric patients with septic shock.

DESIGN

Prospective observational study.

SETTING

Nine-bed PICUs at university referral hospital.

PATIENTS

Children (30 d to 15 yr) with septic shock and Pediatric Logistic Organ Dysfunction (PELOD)-2 score greater than or equal to 10 or Pediatric Risk of Mortality (PRISM) 3 score greater than or equal to 15, who were also receiving at least one inotrope.

INTERVENTION

Patients received 2-4 hour treatment with PMX-DHP 20R column on 2 consecutive days.

MEASUREMENTS AND MAIN RESULTS

We enrolled six children aged 21-167 months old (median, 99-mo old), with a body weight of 10-50 kg (median, 28 kg). All six patients had both PELOD-2 greater than or equal to 10 and PRISM-3 greater than or equal to 15, required invasive mechanical ventilation, and received standard treatment for septic shock before enrollment. We observed significant improvement in PELOD-2 score from baseline to 72 hours after the start of PMX-DHP (mean [95% CI] from 14.3 [12.2-16.5] to 6.0 [0.3-11.7]; p = 0.006). The vasoactive inotropic score (VIS) and lactate concentration also significantly decreased from baseline to 72 hours (VIS, 60 mmol/L [25-95 mmol/L] to 4.0 mmol/L [44.1-12 mmol/L]; p = 0.003; lactate, 2.4 mmol/L [1.0-3.8 mmol/L] to 1.0 mmol/L [0.5-1.5 mmol/L]; p = 0.01). Five of six patients survived. There was no device-related adverse event in these patients.

CONCLUSIONS

In this case series of treatment with PMX-DHP as adjunctive therapy in children with refractory septic shock and high baseline severity, we have shown that patient recruitment is feasible. We have also found that clinical hemodynamic and severity of illness scores at 72 hours may be potential end points for testing in future randomized controlled trials.

Preliminary study on the safety and efficacy of a new polymyxin B‐immoblized resin column in treatment of LPS‐induced sepsis beagles

Background

This study aims to assess the safety and efficacy of direct hemoperfusion using a new polymyxin B‐immobilized resin column (disposable endotoxin adsorber, KCEA) in an endotoxin/ lipopolysaccharide (LPS)‐induced sepsis model.

Methods

Eighteen beagles were randomized into 1 intervention group (KCEA group, n = 6) and 2 control groups (sham group and model group, n = 6 each). Sepsis was induced by continuous intravenous application of 0.5 mg/kg body weight of endotoxin for 60 min. An extracorporeal hemoperfusion device made with KCEA for endotoxin adsorption was used. Model group beagles received standard treatment with fluids and vasoactive drugs, KCEA group beagles received standard treatment and direct hemoperfusion of KCEA for 2 h, and sham group beagles were treated with standard treatment and direct hemoperfusion of a sham column for 2 h.

Results

Good blood compatibility of KCEA was confirmed by assessing clinical parameters. Blood endotoxin peak levels in the KCEA group were significantly lower, resulting in a significant suppression of IL‐6, TNF‐α and procalcitonin, which improved mean arterial pressure and significantly lowered vasopressor demand, thereby protecting organ function and improving survival time and rate. In the KCEA group, MAP was significantly higher over 6 h than those recorded both in the sham group and model group. The 7‐day survival rates of the KCEA, sham and model groups were 50%, 0% and 0%, respectively.

Conclusion

KCEA hemoadsorption was effective at detoxifying circulatory endotoxin and inflammatory mediators and contributed to the decreased mortality rate in the sepsis beagles.

Effectiveness of polymyxin B hemoperfusion for sepsis depends on the baseline SOFA score: a nationwide observational study

BACKGROUND

Polymyxin B hemoperfusion (PMX) aims to treat septic shock by removing endotoxin from the patient's blood. However, the relationship between the severity of the patient's organ damage and the survival benefit of PMX treatment is not clear.

METHODS

We analyzed the efficacy of PMX on adult sepsis patients using the propensity score matching method and the Japanese Diagnosis Procedure Combination (DPC) national inpatient database from April 2018 to March 2020. We stratified the patients into five categories based on their baseline Sequential Organ Failure Assessment (SOFA) score and compared the mortality between PMX-treated and non-treated groups in each category. We also compared continuous hemodiafiltration (CHDF)-, ventilator- and noradrenaline-free days between the groups.

RESULTS

Of 44,177 patients included in the study, 2191 received PMX. After 1:1 propensity score matching, we created matched cohorts of 2033 pairs. PMX significantly improved the survival of the patients in the SOFA score categories of 7-9 and 10-12. On the other hand, there was no significant difference in the survival rate in SOFA score categories of 0-6, 13-15, and 16-24. In analyzing organ support-free days, PMX was also beneficial in the 7-9 and 10-12 SOFA categories compared to other categories.

CONCLUSION

Analysis of a large-scale Japanese inpatient database found a significant association between PMX efficacy and baseline SOFA score. This result indicates higher efficacy in patients with medium SOFA scores in the range of 7-12. The result provides a promising hypothesis for selecting appropriate patients for PMX and should be validated in future RCTs.

Successful treatment of gastrointestinal infection-induced septic shock using the oXiris® hemofilter: A case report

BACKGROUND

Septic shock leads to multiple organ failure, and bacterial endotoxins and endogenous cytokines play essential roles in the pathogenesis. The oXiris^® hemofilter can efficiently adsorb endotoxins and cytokines.

CASE SUMMARY

We admitted a critically ill 59 year-old male patient with gastrointestinal septic shock due to infection by a Gram-negative bacterium and septic acute kidney injury (AKI). Prior to intensive care unit admission, the patient reported intermittent diarrhea and decreased urine output. His blood pressure was 70/40 mmHg, necessitating fluid resuscitation and large doses of noradrenaline. Based on the results of a blood culture and the presence of hypotension, oliguria, and hypoxemia, we diagnosed septic shock, AKI, and multiple organ dysfunction. We administered continuous renal replacement therapy (CRRT) with an oXiris^® hemofilter for 72 h with intermittent continuous veno-venous hemodiafiltration (CVVHDF), and changed the filter every 12 h. After his hemodynamic parameters were stable, we used a traditional filter (AN69 hemofilter) with intermittent CVVHDF. The 72 h CRRT with the oXiris^® hemofilter led to stabilization of his vital signs, marked reductions in disease severity scores, and decreased levels of procalcitonin, endotoxin, and inflammatory factors. After 8 d of CRRT, his kidney function had completely recovered.

CONCLUSION

We conclude that the oXiris^® hemofilter combined with appropriate antibacterial therapy was an effective treatment for this patient with gastrointestinal septic shock.

Blood purification therapy for severe sepsis: a multicenter, observational cohort study in northern Japan

Background

Sepsis is associated with life-threatening organ dysfunction caused by a dysregulated host response to infection. However, no specific therapy has been shown to improve mortality in patients with sepsis. We conducted a study to clarify the utilization status of various BPTs and the clinical characteristics of patients who received BPTs in northern Japan. In addition, the association of various BPTs with clinical outcomes was examined.

Methods

This is a sub-analysis of the Tohoku Sepsis Registry, a multicenter, prospective, observational cohort study. To determine whether BPT was independently associated with in-hospital mortality in patients with severe sepsis, the following analyses were performed. Differences between survivors and non-survivors were assessed using Wilcoxon rank sum tests for continuous variables and Chi-square tests for categorical variables. Univariate logistic regression analysis was used to evaluate the factors associated with in-hospital mortality. In the multivariate logistic regression analysis, adjustments were made for the variables that were significant in the univariate logistic regression analysis. Clinical factors associated with mortality were analyzed.

Results

We enrolled 616 consecutive patients (≥ 18 years) with median Sequential Organ Failure Assessment scores of 8.0. During median of 22 days hospitalization, 139 patients died (mortality 22.6%). 20.7% of patients with severe sepsis received any type of BPT (mortality 38.6%). BPT consisted of 65.1% continuous renal replacement therapy (CRRT) with renal indication (mortality 48.8%), 26.0% CRRT with non-renal indication (mortality 21.2%), 22.2% intermittent renal replacement therapy (mortality 32.1%), and 33.1% polymyxin B-immobilized fiber column-direct hemoperfusion (mortality 42.9%). Meanwhile, no BPT group (mortality 18.5%) showed a significantly lower mortality than any BPT group. Besides, in multivariate analyses, all BPT modes were not independently associated with all-cause mortality.

Conclusions

This study suggested the clinical status of BPTs for severe sepsis patients in northern Japan. Among all types of BPT, continuous renal replacement therapy (CRRT) for renal indication was most frequently selected. Severe sepsis patients received BPT had a higher mortality and severity; however, the BPT implementation may not be associated with mortality.

Trial registration UMIN-CTR, UMIN000010297, Registered on 22 March 2013, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000012055).

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Advances in the Development of Biomaterials for Endotoxin Adsorption in Sepsis

Sepsis, a life-threatening and intractable disease without any specific treatment, is activated by endotoxin. Some attempts at removing endotoxin to treat sepsis from the blood circulation using different hemoperfusion cartridges have been proposed recently, but they have failed to reduce the mortality of severe septic patients. This review summarizes the latest advances in the development of endotoxin adsorbents. In particular, we highlight two critical parameters for endotoxin adsorbents when they are applied in blood purification: the dissociation constant and the maximum adsorption capacity. We also discuss potential challenges and research directions for the future development of endotoxin adsorbents.

Surface Modification of Reduced Graphene Oxide Beads: Integrating Efficient Endotoxin Adsorption and Improved Blood Compatibility

As a pathogenic toxin, endotoxins are the culprit for endotoxemia and can be generally removed from the blood by hemoperfusion. Reduced graphene oxide (rGO) is a promising endotoxin sorbent for hemoperfusion owing to its excellent adsorption capacity, but it has the side effect of nonspecific adsorption and low blood compatibility. Polymyxin B (PMB) acts as an organic affinity ligand that can specifically bind endotoxins. As a natural anticoagulant, heparin (Hep) can reduce the risk of coagulation and improve the blood compatibility of materials. Herein, an rGO bead adsorbent was prepared by coupling with PMB and Hep and used for endotoxin adsorption; in this, polydopamine (pDA) served as an active coating for immobilization of PMB and further coupling with Hep. The physicochemical characteristics indicated that PMB and Hep were successfully immobilized on rGO beads with a hierarchical pore structure. PMB endowed rGO beads with higher adsorption capacity (143.84 ± 3.28 EU/mg) and good adsorption selectivity for endotoxins. Hep significantly improved the blood compatibility of rGO beads. These modified rGO beads also achieved good adsorption capacity and adsorption selectivity for endotoxins in plasma, serum, or blood. Therefore, rGO/pDA/PMB/Hep beads are potential adsorbents for endotoxins in hemoperfusion.

Impact of Extended Duration of Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion on Hemodynamics, Vasoactive Substance Requirement, and Pulmonary Oxygenation in Patients with Sepsis: An Observational Study

INTRODUCTION

Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is used for patients with septic shock, and the recommended hemoperfusion period is 2 h. However, it remains unclear whether the optimal duration is 2 h or longer. The purpose of this study was to compare the effects of PMX-DHP between conventional and longer duration of PMX-DHP.

METHODS

We retrospectively investigated 103 patients with sepsis who underwent PMX-DHP. The demographic data, routine biochemistry, microbiological data, and primary infection site were reviewed in the medical chart. The acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, heart rate, mean arterial pressure (MAP), vasoactive-inotropic score (VIS), and PaO2/FiO2, at baseline and day 3, were compared between the standard group (2 h of PMX-DHP) and the extended group (>2 h of PMX-DHP).

RESULTS

Median MAP was significantly lower and median VIS was significantly higher in the extended group at baseline (p < 0.05, 0.01, respectively) There were no significant differences in APACHE II score, SOFA score, and PaO2/FiO2 at baseline between the 2 groups. The increase of MAP and the decrease in VIS from baseline to day 3 were significantly greater in the extended group (p < 0.01, respectively). In the extended group, increase in PaO2/FiO2 was significantly larger in the patients who underwent ≥8 h duration than that in patients who underwent <8 h duration (p < 0.01). The ventilator-free days, the incidence of continuous renal replacement therapy, and the 28-day mortality were not different between the groups.

DISCUSSION/CONCLUSIONS

Longer duration of PMX-DHP was associated with the improved MAP and decreased volume of vasoactive-inotropic agents compared with the conventional duration. Eight and longer hours duration of PMX-DHP was associated with the improvement in the pulmonary oxygenation. Further studies are needed to confirm the efficacy of longer duration of PMX-DHP in patients with septic shock.

Effects of Polymyxin B Hemoperfusion on Septic Shock Patients Requiring Noradrenaline: Analysis of a Nationwide Administrative Database in Japan

INTRODUCTION

Polymyxin B hemoperfusion (PMX) reduces endotoxin in septic shock patients' blood and can improve hemodynamics and organ functions. However, its effects on the reduction of septic shock mortality are controversial.

METHODS

Using the Japanese diagnosis procedure combination database from April 2016 to March 2019, we identified adult septic shock patients treated with noradrenaline. This study used propensity score matching to compare the outcome between PMX-treated and non-treated patients. The primary endpoint was 28-day mortality, counting from the day of noradrenaline initiation. The secondary endpoints were noradrenaline-, ventilator-, and continuous hemodiafiltration (CHDF)-free days at day 28.

RESULTS

Of 30,731 eligible patients, 4,766 received PMX. Propensity score matching produced a matched cohort of 4,141 pairs with well-balanced patient backgrounds. The 28-day survival rate was 77.9% in the PMX group and 71.1% in the control group (p < 0.0001). Median days of noradrenalin-, CHDF-, and ventilator-free days were 2 days (p < 0.0001), 2 days (p < 0.0001), and 6 days (p < 0.0001) longer in the PMX group than in the control group, respectively. When stratified with the maximum daily dose of noradrenaline, the PMX group showed a statistically significant survival benefit in the groups with noradrenaline dose <20 mg/day but not in the noradrenaline group dose ≥20 mg/day.

CONCLUSION

Analysis of large Japanese databases showed that septic shock patients who received noradrenaline might benefit from PMX treatment.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Direct hemoperfusion using a polymyxin B-immobilized polystyrene column for COVID-19

Objective

To evaluate the efficacy and safety of direct hemoperfusion using a polymyxin B‐immobilized polystyrene column (PMX‐DHP) in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐positive pneumonia patients.

Methods

This study was a case series conducted at a designated infectious diseases hospital. Twelve SARS‐CoV‐2‐positive patients with partial pressure of arterial oxygen/percentage of inspired oxygen (P/F) ratio < 300 were treated with PMX‐DHP on two consecutive days each during hospitalization. We defined day 1 as the first day when PMX‐DHP was performed. PMX‐DHP efficacy was assessed on days 7 and 14 after the first treatment based on eight categories. Subsequently, improvement in P/F ratio and urinary biomarkers on days 4 and 8, malfunctions, and ventilator and extracorporeal membrane oxygenation avoidance rates were also evaluated.

Results

On day 14 after the first treatment, disease severity decreased in 58.3% of the patients. P/F ratio increased while urine β2‐microglobulin decreased on days 4 and 8. Cytokine measurement pre‐ and post‐PMX‐DHP revealed decreased levels of interleukin‐6 and the factors involved in vascular endothelial injury, including vascular endothelial growth factor. Twenty‐two PMX‐DHPs were performed, of which seven and five PMX‐DHPs led to increased inlet pressure and membrane coagulation, respectively. When the membranes coagulated, the circuitry needed to be reconfigured. Circuit problems were usually observed when D‐dimer and fibrin degradation product levels were high before PMX‐DHP.

Conclusions

Future studies are expected to determine the therapeutic effect of PMX‐DHP on COVID‐19. Because of the relatively high risk of circuit coagulation, coagulation capacity should be assessed beforehand.

Effectiveness of polymyxin B-immobilized hemoperfusion against sepsis and septic shock: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of Polymyxin B-immobilized hemoperfusion (PMX-HP) against sepsis or septic shock.

METHODS

We searched databases (PubMed, EMBASE and Cochrane Library) to identify eligible randomized controlled trials (RCTs). The primary outcomes we included in this review were mortality at the longest follow-up available and serious adverse events associated with treatments. We used the Cochrane risk of bias assessment tool to evaluate risk of bias. Trial Sequential Analysis (TSA) was performed to assess the conclusion reached in our research.

RESULTS

Thirteen studies including 1163 patients were identified. Use of PMX-HP could reduce overall mortality [relative risk (RR) 0.68, 95% confidence interval (CI) 0.51-0.91, P = 0.01]. An interesting finding was that the mortality of patients in Acute Physiology and Chronic Health Evaluation (APACHE II) scores <25 group (RR 0.64, 95% CI 0.52-0.78, P < 0.0001) and sepsis group (RR 0.48, 95% CI 0.32-0.72, P = 0.0003) significantly decreased after PMX-HP treatment. The result also showed that PMX-HP could reduce endotoxin levels [Standardized mean difference (SMD) -1.53, 95% CI -2.92- -0.13, P = 0.03] and improve mean arterial pressure (SMD 1.07, 95% CI 0.14-2.01, P = 0.02). Serious adverse events between the PMX-HP group and standard therapy group were not significantly different (RR 2.16, 95% CI 0.97-4.80, I² = 0%, P = 0.06). However, TSA did not provide conclusive evidence and more high quality RCTs were required.

CONCLUSION

Using PMX-HP to treat patients with less severe sepsis can reduce overall mortality and is safe. Treatment efficacy may benefit from the reduction of endotoxin level and the improvement of hemodynamics. More high quality RCTs are required to further evaluate the clinical role of PMX-HP against severe sepsis or septic shock.

Cytokine Adsorption to Polymyxin B-Immobilized Fiber: An in vitro Study

BACKGROUND

Acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF) are episodes of acute respiratory worsening characterized by diffuse alveolar damage superimposed on usual interstitial pneumonia. Direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) is reported to have beneficial effects on the respiratory status and outcome in patients with AE-IPF although its mechanism of action is not fully elucidated.

OBJECTIVE

To investigate whether and how the PMX-immobilized fiber (PMX-F) adsorbs cytokines because reduction of the serum levels of various cytokines has been noted in AE-IPF patients receiving PMX-DHP.

METHODS

The propensity of recombinant cytokines for adsorption onto PMX-F was examined by incubating cytokines with heparin-coated or uncoated PMX-F for 2 h at 37°C. Cytokines were quantitated by multiplex bead array assay or ELISA.

RESULTS

Interleukin (IL)-8, RANTES, platelet-derived growth factor-bb, and transforming growth factor-β were substantially adsorbed onto PMX-F without heparin coating. The adsorbed cytokines could be eluted with PMX sulfate, indicating that the PMX moiety is involved in cytokine adsorption. Importantly, although IL-1β, monocyte chemoattractant protein-1, fibroblast growth factor 2, and vascular endothelial growth factor-A were adsorbed onto PMX-F to lesser extents, the adsorption was enhanced by heparin coating of PMX-F. Furthermore, heparin-coated PMX-F acquired the capability to adsorb IL-6, IL-12, and tumor necrosis factor α. An affinity of heparin to PMX was determined (Kd = 0.061 ± 0.032 mg/mL), which accounts for the enhanced cytokine adsorption onto PMX-F upon heparin coating.

CONCLUSIONS

Various cytokines involved in inflammation, fibrosis, and vascular permeability were shown to be adsorbed onto PMX-F. Removal of multiple cytokines may be associated with positive impacts of PMX-DHP in patients with AE-IPF.

Galápagosization of sepsis management in Japan: a nationwide survey of current practices

Aim

Sepsis treatment has been standardized in many countries worldwide. However, treatment of sepsis in Japan has developed independently, and how Japanese physicians actually treat sepsis patients nationwide remains uninvestigated. The aim of this study was to clarify the current practice for septic patients in Japan and how it differs from standard care throughout the world.

Methods

This study was designed as a prospective, cross‐sectional, self‐reported questionnaire‐ and Web‐based electronic survey in Japan. The survey was undertaken to assess respondents’ clinical practices and preferences regarding treatment strategies, sepsis assessment, and management in the setting of critical illness. An exploratory factor analysis and a hierarchical cluster analysis were carried out to identify the treatments distinctive to Japan, called “Galápagos therapies”.

Results

The final analysis included 295 respondents. According to the factor analysis, we defined anticoagulant therapy for disseminated intravascular coagulation, antimediator renal replacement therapy, and others as Galápagos therapies. These Galápagos therapies were undertaken by approximately two‐thirds of the Japanese physicians who responded. We classified Japanese physicians according to three patterns of clinical practice carried out for sepsis: (i) those who do not perform Galápagos therapies but do perform worldwide standardized care, (ii) those who perform Galápagos therapies on top of worldwide standardized care, (iii) those who do not perform worldwide standardized care.

Conclusion

On the basis of a nationwide questionnaire‐based survey in Japan, we clarified distinctive sepsis treatments performed in Japan, such as antimediator renal replacement therapy and treatment for sepsis‐induced disseminated intravascular coagulation.

Early use of endotoxin absorption by oXiris in abdominal septic shock: A case report

RATIONALE

Septic shock leads to multiple organ failure and increases mortality rate. We reported a critical patient with abdominal septic shock, which was the first case successfully treated with continuous renal replacement therapy (CRRT) and a newly designed endotoxin removal device oXiris in mainland China.

PATIENT CONCERNS

A 51-year-old man developed gastric ulcer perforation after resection of a benign peritoneal tumor and had a second abdominal surgery. His blood pressure decreased to 70/40 mm Hg with oliguria, requiring large doses of noradrenaline and intravenous fluid for resuscitation. The abdominal cavity was not sutured after the second open surgery due to severe abdominal infection and distention. His leukocyte count was over 30109/L, while the blood lactic acid was 12.5 mmol/L and procalcitonin (PCT) was >100 ng/mL.

DIAGNOSIS

Since the bacterial culture of peritoneal exudate showed positive with Enterobacter aerogenes and Pseudomonas aeruginosa after the second surgery, and the patient had severe low blood pressure, hyoxemia and oliguria, combined with the laboratory tests results, he was diagnosed with Gram-negative related septic shock, acute kidney injury, and multiple organ dysfunction.

INTERVENTIONS

CRRT with oXiris membrane was performed for 80hours and followed by AN69 ST membranes during the subsequent 27 days. Antibiotics together with other medical treatment were applied to the patient in the meantime.

OUTCOMES

At the end of 80 hours treatment with oXiris, PCT of the patient had decreased to 14.52 ng/mL and lactic acid decreased to 4.2 mmol/L. The total sequential organ failure assessment (SOFA) score decreased from 15 to 11. Urine output steadily increased to 250 mL/h, and vital signs and blood pressure were stable without noradrenaline. At the end of the 27 days of conventional CRRT, his kidney function had completely recovered with a total sequential organ failure assessment score (SOFA score) of 6.

LESSONS

oXiris, with its enhanced endotoxin adsorption, appeared to accelerate improvement in organ dysfunction and ultimate survival in our patient. In critical patients with abdominal septic shock, oXiris is an important adjunctive consideration to supplement definitive source control and antimicrobial therapy.

Effects of endotoxin adsorber hemoperfusion on sublingual microcirculation in patients with septic shock: a randomized controlled trial

Background

Endotoxins can induce an excessive inflammatory response and result in microcirculatory dysfunction. Polymyxin-B hemoperfusion (PMX-HP) has been recognized to effectively remove endotoxins in patients with sepsis and septic shock, and a rat sepsis model revealed that PMX-HP treatment can maintain a better microcirculation. The primary aim of this study was to investigate the effect of PMX-HP on microcirculation in patients with septic shock.

Methods

Patients with septic shock were enrolled and randomized to control and PMX-HP groups. In the PMX-HP group, patients received the first session of PMX-HP in addition to conventional septic shock management within 24 h after the onset of septic shock; the second session of PMX-HP was provided after another 24 h as needed.

Results

Overall, 28 patients finished the trial and were analyzed. The mean arterial pressure and norepinephrine infusion dose did not differ significantly between the control and PMX-HP groups after PMX-HP treatment. At 48 h after enrollment, total vessel density (TVD) and perfused vessel density (PVD) were higher in the PMX-HP group than in the control group [TVD 24.2 (22.1–24.9) vs. 21.1 (19.9–22.9) mm/mm²; p = 0.007; PVD 22.9 (20.9–24.9) vs. 20.0 (18.9–21.6) mm/mm², p = 0.008].

Conclusions

This preliminary study observed that PMX-HP treatment improved microcirculation but not clinical outcomes in patients with septic shock at a low risk of mortality. Nevertheless, larger multicenter trials are needed to confirm the effect of PMX-HP treatment on microcirculation in patients with septic shock at intermediate- and high-risk of mortality.

Trial registration ClinicalTrials.gov protocol registration ID: NCT01756755. Date of registration: December 27, 2012. First enrollment: October 6, 2013. https://clinicaltrials.gov/ct2/show/NCT01756755

Beneficial effect modification on survival outcome of sepsis between ART-123 and polymyxin B‑immobilised haemoperfusion: a nationwide Japanese registry study

Background

Although recently published randomised controlled trials did not confirm significant positive effect of ART-123 or polymyxin B‑immobilised haemoperfusion (PMX-HP) on survival outcome, previous studies using a dataset of 3195 patients with sepsis registered at 42 intensive care units throughout Japan revealed significantly reduced mortality following these treatments. A study has suggested the efficacy of combination therapy with ART-123 and PMX-HP; however, it did not evaluate the effect modification between them. We hypothesised that coadministration of ART-123 and PMX-HP has a significant positive effect modification on survival outcome. The purpose of this study was to evaluate the effect modification between ART-123 and PMX-HP treatment on the survival outcome of sepsis using post hoc analysis of the dataset of the Japan Septic Disseminated Intravascular Coagulation registry.

Results

Of the 3195 patients recorded in the registry, 2350 were analysed. The product term between ART-123 and PMX-HP was analysed by the Cox regression model to evaluate significance. The primary outcome of this study was hospital mortality. Although the administration of ART-123 was independently positively associated with survival outcome (adjusted hazard ratio [HR]: 0.834, 95% confidence interval [CI] 0.695–0.999; P = 0.049) in the model prior to the introduction of the product term, a significant effect modification on survival outcome was observed between the administration of ART-123 and PMX-HP treatment (adjusted HR: 0.667, 95% CI 0.462–0.961; P = 0.030).

Conclusions

The main effect of the administration of ART-123 may be beneficial for survival outcome in patients with sepsis. In addition, a significant beneficial effect modification on survival outcome was observed between the administration of ART-123 and PMX-HP treatment.

Septicemia, necrotizing fasciitis, and peritonitis due to Vibrio vulnificus treated with early use of polymyxin B hemoperfusion in a patient undergoing CAPD: a case report

Background

Vibrio vulnificus infection is a rare but fatal foodborne illness. Here, we report a case of Vibrio vulnificus peritonitis followed by severe septicemia in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD) who was treated with hemoperfusion using polymyxin B immobilized fiber.

Case presentation

A 63-year-old man undergoing CAPD was admitted to the emergency room due to general weakness, fever, and abdominal pain with hazy dialysate. Two days before admission, he had eaten raw fish. Initial laboratory tests including peritoneal fluid analysis suggested peritonitis. Despite empirical intraperitoneal antibiotic treatment, his fever did not subside, and multiple vesicles on the extremities newly appeared. The result of initial peritoneal fluid culture and blood cultures reported Vibrio vulnificus as the most likely causative pathogen. Hemoperfusion with polymyxin B immobilized fiber was performed to control gram-negative bacterial septicemia with antibiotics targeting the pathogenic organism. The patient recovered completely and was discharged without complications.

Discussion and conclusion

Suspicion of Vibrio vulnificus infection in susceptible immunocompromised patients is important for early diagnosis and prompt management. Peritonitis should be noted as a clinical manifestation of Vibrio vulnificus infection in CAPD patients, and polymyxin B hemoperfusion along with proper antibiotics could be considered as a treatment option.

Identifying Septic Shock Populations Benefitting From Polymyxin B Hemoperfusion: A Prospective Cohort Study Incorporating a Restricted Cubic Spline Regression Model

INTRODUCTION

Polymyxin B hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that removes circulating endotoxin. However, PMX-HP has seldom achieved expectations in randomized trials targeting nonspecific overall sepsis patients. If used in an optimal population, PMX-HP may be beneficial. This study aimed to identify the optimal population for PMX-HP in patients with septic shock.

METHODS

We used a prospective nationwide cohort targeting consecutive adult patients with severe sepsis (Sepsis-2) in 59 intensive care units in Japan. Associations between PMX-HP therapy and in-hospital mortality were assessed using multivariable Cox proportional hazard regression models. To identify best targets for PMX-HP, we developed a non-linear restricted cubic spline model including two-way interaction term (treatment × Acute Physiology and Chronic Health Evaluation [APACHE] II score/Sequential Organ Failure Assessment [SOFA] score) and three-way interaction term (treatment × age × each score).

RESULTS

The final study cohort comprised 741 sepsis patients (92 received PMX-HP, 625 did not). Cox proportional hazards regression model adjusted for the covariates suggested no association between PMX-HP therapy and improved mortality overall. Effect modification of PMX-HP by APACHE II score was statistically significant (P for interaction = 0.189) but non-significant for SOFA score (P for interaction = 0.413). Three-way interaction analysis revealed suppressed risk hazard in the PMX-HP group versus control group only in septic shock patients with high age and in the most severe subset of both scores, whereas increased risk hazard was observed in those with high age but in the lower severity subset of both scores.

CONCLUSIONS

Our results suggested that although PMX-HP did not reduce in-hospital mortality among overall septic shock patients, it may benefit a limited population with high age and higher disease severity.

Experimental model for removal of snake venom via hemoperfusion in rats

OBJECTIVE

To examine the efficiency of hemoperfusion in removing South American rattlesnake (Crotalus durissus terrificus) venom from rats compared with neutralization by antivenom.

DESIGN

An exploratory experimental investigation in rats involving the injection of snake venom with or without subsequent hemoperfusion or antivenom administration.

SETTING

Basic animal research laboratory in a private university.

ANIMALS

Normal, healthy male Wistar rats (0.29-0.40 kg, 3-6 months old) from a commercial breeder.

INTERVENTIONS

Four experimental groups of randomly allocated rats (n = 3/group) were studied: Group 1: rats were injected with a single dose of venom (5 mg/kg, IM, in the right thigh) with no other treatment; blood samples were collected minutes before death to determine leukocyte, platelet, and erythrocyte counts; Group 2 (Control): rats underwent hemoperfusion alone for 60 min using a hemoperfusion cartridge designed for protein adsorption (by granulated charcoal) and protein precipitation (by tannic acid); Group 3 (Venom + antivenom): rats were injected with venom (5 mg/kg, IM) and, 10 min later, were treated with antivenom at the venom:antivenom ratio recommended by the manufacturer; Group 4 (Venom + hemoperfusion): Rats were injected with venom (5 mg/kg, IM) and, 10 min later, were hemoperfused for 60 min. In groups 2-4, blood samples were collected for leukocyte, platelet, and erythrocyte counts 24 h after venom.

MEASUREMENTS AND MAIN RESULTS

Rats injected with venom alone (Group 1) developed signs of neurotoxicity and ataxia and died in 9.0 ± 0.43 h but showed no changes in leukocyte or erythrocyte counts. In contrast, there were no deaths in groups 2-4. The lack of deaths in Groups 3 and 4 indicated that antivenom and hemoperfusion, respectively, protected against the lethal effects of the venom.

CONCLUSIONS

Hemoperfusion with a double-action hemoperfusion cartridge capable of protein adsorption and precipitation protected rats against C. d. terrificus venom.

Clinical Effects and Outcomes After Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion Treatment for Septic Shock in Preterm Neonates

OBJECTIVES

To compare the effectiveness and mortality of early-onset sepsis or late-onset sepsis treatments with polymyxin B-immobilized fiber column direct hemoperfusion in terms of effectiveness and mortality in preterm infants with septic shock.

DESIGN

Retrospective cohort study.

SETTING

Neonatal ICU within a tertiary care hospital.

PATIENTS

Of 1,115 patients, 49 had blood culture-proven sepsis between January 2013 and December 2018; six and five patients with septic shock had undergone polymyxin B-immobilized fiber column direct hemoperfusion treatment for early-onset sepsis (early-onset sepsis group) and late-onset sepsis (late-onset sepsis group), respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline demographic characteristics of both groups were similar. The time from decision to treatment induction was significantly shorter in the early-onset sepsis group than that in the late-onset sepsis group (p = 0.008). The mortality rate after 28 days of treatment and the hospital mortality were significantly lower in the early-onset sepsis group than in the late-onset sepsis group (p = 0.026 and 0.015, respectively). The PaO2/FIO2 ratio was significantly higher in the early-onset sepsis group than in the late-onset sepsis group at the end of the treatment (p = 0.035). In addition, median arterial-to-alveolar oxygen tension ratio significantly improved from 0.19 to 0.55, and median blood pressure also significantly improved from 32.5 to 40.0 mm Hg after the treatment in the early-onset sepsis group. Interleukin-6 levels significantly decreased after treatment in the early-onset sepsis group (p = 0.037). The Pediatric Risk of Mortality III score was similar between the early-onset sepsis and late-onset sepsis groups before and after the treatment. Intraventricular hemorrhage events occurred in both groups, but with no significant differences (p = 0.175).

CONCLUSIONS

Polymyxin B-immobilized fiber column direct hemoperfusion treatment for preterm infants with septic shock due to early-onset sepsis is associated with earlier hemodynamic and respiratory status improvements and with lower mortality than that due to late-onset sepsis. Early neonatal septic shock detection and polymyxin B-immobilized fiber column direct hemoperfusion induction may improve the prognosis of affected infants.

Blood Purification and Mortality in Sepsis and Septic Shock: A Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

Sepsis and septic shock are severe inflammatory conditions related to high morbidity and mortality. We performed a systematic review with meta-analysis of randomized trials to assess whether extracorporeal blood purification reduces mortality in this setting.

METHODS

Electronic databases were searched for pertinent studies up to January 2019. We included randomized controlled trials on the use of hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique in comparison to conventional therapy in adult patients with sepsis and septic shock. The primary outcome was mortality at the longest follow-up available. We calculated relative risks and 95% CIs. The grading of recommendations assessment, development and evaluation methodology for the certainty of evidence was used.

RESULTS

Thirty-seven trials with 2,499 patients were included in the meta-analysis. Hemoperfusion was associated with lower mortality compared to conventional therapy (relative risk = 0.88 [95% CI, 0.78 to 0.98], P = 0.02, very low certainty evidence). Low risk of bias trials on polymyxin B immobilized filter hemoperfusion showed no mortality difference versus control (relative risk = 1.14 [95% CI, 0.96 to 1.36], P = 0.12, moderate certainty evidence), while recent trials found an increased mortality (relative risk = 1.22 [95% CI, 1.03 to 1.45], P = 0.02, low certainty evidence); trials performed in the United States and Europe had no significant difference in mortality (relative risk = 1.13 [95% CI, 0.96 to 1.34], P = 0.15), while trials performed in Asia had a positive treatment effect (relative risk = 0.57 [95% CI, 0.47 to 0.69], P < 0.001). Hemofiltration (relative risk = 0.79 [95% CI, 0.63 to 1.00], P = 0.05, very low certainty evidence) and plasmapheresis (relative risk = 0.63 [95% CI, 0.42 to 0.96], P = 0.03, very low certainty evidence) were associated with a lower mortality.

CONCLUSIONS

Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock. Existing evidence of moderate quality and certainty does not provide any support for a difference in mortality using polymyxin B hemoperfusion. Further high-quality randomized trials are needed before systematic implementation of these therapies in clinical practice.

Case Report: Successful Use of Extracorporeal Therapies After ECMO Resuscitation in a Pediatric Kidney Transplant Recipient

The combination of extracorporeal membrane oxygenation (ECMO) and extracorporeal blood purification in children is rarely used due to small total blood volumes, risks of hemodynamic instability and a negative association between volume of blood transfusion and patient outcome. To our knowledge, this is the first description of a multimodal extracorporeal detoxication in the setting of ECMO in a post-kidney-transplant child on immunosuppression. We describe a case of a 30-months old child, who was extracorporeally resuscitated after cardiac arrest during kidney transplantation surgery and additionally treated with a number of extracorporeal blood purification methods (plasma exchange, CytoSorb, and lipopolysaccharide adsorption) in the setting of immunosuppression therapy. This case report shows the successful use of multimodal extracorporeal therapies for a good patient outcome. The lack of response to CytoSorb therapy might suggest an occult infection and not necessarily failure of treatment.

Hemoperfusion plus continuous veno-venous hemofiltration in the treatment of patients with multiple organ failure after wasp stings

PURPOSE

This study aimed to evaluate the clinical effects of hemoperfusion plus continuous veno-venous hemofiltration in the treatment of patients with multiple organ failure after wasp stings and investigate its impacts on cytokines.

METHODS

A total of 12 patients with multiple organ failure after wasp stings admitted to Xijing Hospital were included in the present study between January 2017 and January 2019. All patients received hemoperfusion plus continuous veno-venous hemofiltration treatment in addition to conventional treatment after admission. Procedure of treatment was conducted as the following: hemoperfusion (2 h/day) and followed by continuous veno-venous hemofiltration (22 h/day) for at least 5 days. Patients' clinical features, serum laboratory tests, and hemodynamic variables were monitored. The blood samples were taken to measure the changes of plasma cytokines.

RESULTS

All 12 patients survived in the observation period. After hemoperfusion plus continuous veno-venous hemofiltration treatment, there were significant improvements in indicators of liver function, renal function, state of consciousness, and mediators in blood circulation, including alanine transaminase, aspartate transaminase, creatine kinase, blood urea nitrogen, serum creatinine, myoglobin, C-reactive protein, and so on. In these patients, acid-base metabolism returned to normal levels; Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II score, and Sequential Organ Failure Assessment score lowered markedly. Furthermore, the plasma levels of interleukin 1β, interleukin 4, interleukin 6, interleukin 8, and interleukin 10 in these patients were significantly decreased; no significant change was shown in the level of tumor necrosis factor α.

CONCLUSION

Our results revealed that hemoperfusion plus continuous veno-venous hemofiltration was effective in the management of patients with multiple organ failure after wasp sting via the non-specific removal of the wasp venom and inflammatory cytokines.

A systematic review of the efficacy of direct hemoperfusion with a polymyxin B-immobilized fibre column to treat rapidly progressive interstitial pneumonia

Objectives

Rapidly progressive interstitial pneumonia is a fatal disease with no established therapeutic options. The aim of this systematic review is to clarify the efficacy of interstitial pneumonia treatment utilizing direct hemoperfusion with a polymyxin B-immobilized fibre column.

Methods

All patients with adult-onset rapidly progressive interstitial pneumonia including acute exacerbation of underlying chronic interstitial pneumonia were eligible. Primary studies of any design, which compared outcomes of direct hemoperfusion with a polymyxin B-immobilized fibre column treatment such as oxygenation and all-cause mortality with those of conventional therapy, were included. Electronic databases such as Medline and EMBASE were searched through October 7, 2018, and ICHUSHI, the largest database for medical articles in Japan, was also searched. Two reviewers independently extracted the relevant data and assessed the risk of bias in individual studies. The results were reported qualitatively due to substantial heterogeneity between studies.

Results

Out of 775 records retrieved, 10 reports were eligible and 8 of them were included for further analysis. They were all retrospective studies including a total of 327 patients and contained some risk of bias. There was variation in the administration method of direct hemoperfusion with a polymyxin B-immobilized fibre column treatment such as the timing, frequency, duration and interval. Multivariate analyses of only two studies with historical controls demonstrated beneficial effects of direct hemoperfusion with a polymyxin B-immobilized fibre column treatment over conventional therapy with all-cause mortality hazard ratios of 0.345 (95% confidence interval: 0.127-0.936) and 0.505 (95% confidence interval: 0.270-0.904), respectively. A significant difference of an improvement in the ratio of partial arterial oxygen pressure to the fraction of inspired oxygen in-between two treatment groups was also reported in two studies utilizing historical controls with mean differences of 56.8 and 57.5 mmHg, respectively.

Conclusions

There is currently insufficient data to support the use of direct hemoperfusion with a polymyxin B-immobilized fibre column treatment for rapidly progressive interstitial pneumonia. It should be instituted for research purposes only until new evidence is available.

Marine Biosurfactants: Biosynthesis, Structural Diversity and Biotechnological Applications

Biosurfactants are amphiphilic secondary metabolites produced by microorganisms. Marine bacteria have recently emerged as a rich source for these natural products which exhibit surface-active properties, making them useful for diverse applications such as detergents, wetting and foaming agents, solubilisers, emulsifiers and dispersants. Although precise structural data are often lacking, the already available information deduced from biochemical analyses and genome sequences of marine microbes indicates a high structural diversity including a broad spectrum of fatty acid derivatives, lipoamino acids, lipopeptides and glycolipids. This review aims to summarise biosyntheses and structures with an emphasis on low molecular weight biosurfactants produced by marine microorganisms and describes various biotechnological applications with special emphasis on their role in the bioremediation of oil-contaminated environments. Furthermore, novel exploitation strategies are suggested in an attempt to extend the existing biosurfactant portfolio.

Association between endotoxemia and enterocyte injury and clinical course in patients with gram-positive septic shock: A posthoc analysis of a prospective observational study

Endotoxemia often occurs in patients with gram-positive infections. The possible mechanism is thought to be bacterial translocation after enterocyte hypoperfusion injury. However, the association between endotoxemia and enterocyte injury among patients with gram-positive septic shock has never been assessed. The aim of this study was to evaluate the association between endotoxemia and enterocyte injury in gram-positive septic shock patients and to evaluate the association among endotoxemia, subsequent clinical course, and other related factors.This was a posthoc analysis of a prospective observational study that evaluated the capability of intestinal fatty acid-binding protein (I-FABP), an indicator of enterocyte injury, to predict mortality. Among 57 patients in septic shock, those whose causative microorganisms were gram positive were included. The correlation between endotoxin activity (EA), which indicates endotoxemia, and I-FABP levels upon admission to the intensive care unit (ICU), the clinical course, and other related factors were evaluated.A total of 21 patients were examined. One-third of the patients presented with high EA levels at the time of ICU admission. However, there was no significant correlation between EA and I-FABP levels (Spearman ρ = 0.002, P = .993). Additionally, high EA levels were not associated with abdominal complications after ICU admission or mortality. Similarly, high EA levels were not associated with severity scores, inotropic scores, or lactate levels upon ICU admission, which were previously reported to be factors related to high EA levels.In this posthoc analysis, no correlation was observed between endotoxemia and enterocyte injury among patients in gram-positive septic shock. Additionally, high EA levels were not associated with the clinical course and reported factors related to endotoxemia. Although our results need to be validated in a large prospective cohort study, hypoperfusion enterocyte injury might not be a cause of endotoxemia in these patients. Thus, if there is no correlation between EA and I-FABP levels, other mechanisms that induce high EA levels among patients with gram-positive septic shock should be elucidated.

Comparative Evaluation of Endotoxin Activity Level and Various Biomarkers for Infection and Outcome of ICU-Admitted Patients

Here, we concurrently measured the endotoxin activity (EA) level and levels of multiple biomarkers in patient blood obtained within 24 h after being admitted into the intensive care unit (ICU) and analyzed whether there were links between these markers and their associations with patient conditions and outcomes. The EA levels highly correlated with disease severity and patient survival, and showed a significant positive association with levels of lactate, procalcitonin, presepsin, and interleukin-6. Notably, the EA level was the marker that most highly correlated with the results of blood culture, and the presepsin level was the marker most highly correlated with the survival outcome at 28 days. Thus, the optimal biomarker should be selected based on whether it will be used to discriminate the presence of an infection or to predict survival.

Label-Free Bacterial Toxin Detection in Water Supplies Using Porous Silicon Nanochannel Sensors

Lipopolysaccharides (LPS) are the major component of the outer membrane of all Gram-negative bacteria and some cyanobacteria and are released during growth and cell death. LPS pose a potential health risk in water, causing acute respiratory illnesses, inhalation fever, and gastrointestinal disorders. The need for rapid and accurate detection of LPS has become a major priority to facilitate more timely and efficacious intervention and, hence, avoid unsafe water distribution. In this context, a porous silicon membrane (pSiM)-based electrochemical biosensor was developed for direct and sensitive detection of LPS. pSiM, featuring arrays of nanochannels, was modified with polymyxin B (PmB), an antimicrobial peptide with strong affinity to LPS. Detection of LPS was based on measuring the changes in the diffusion through the nanochannels of an electroactive species added in solution, caused by the nanochannel blockage upon LPS binding to PmB. Results showed a limit of detection of 1.8 ng/mL, and a linear response up to 10,000 ng/mL spiked in buffer. Selectivity of the sensor toward potential interfering species in water supplies was also assessed. Sensor performance was then evaluated in water samples from a water treatment plant (WTP), and detection of LPS well below the levels encountered in episodes of water contamination and in humidifiers was demonstrated. The same platform was also tested for bacterial detection including Pseudomonas aeruginosa and Escherichia coli spiked in water samples from a WTP. Considering its performance characteristics, this platform represents a promising screening tool to identify the presence of LPS in water supplies and provide early warning of contamination events.