Background: Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies.
Objective: The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany.
Method: To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies.
Results: In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis.
Discussion: Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given.
Zusammenfassung: HINTERGRUND: Hämoperfusion ist ein Verfahren zur Elimination von endogenen und exogenen Toxinen und schädlichen Mediatoren durch Adsorption. Mittlerweile vertreiben diverse Anbieter Systeme mit unterschiedlichen Technologien.
Fragestellung: Ziel dieser Arbeit ist es zu bewerten, welche Chancen, Risiken und Evidenz die unterschiedlichen Systeme haben, wie die Funktionsweise ist und für welche Indikationen sie in Deutschland zugelassen sind.
Methodik: Zur Zielerreichung wurde eine narrative Bewertung der vorhandenen Literatur und Leitlinien für verschiedene Indikationen vorgenommen. Der Fokus lag dabei auf In-vivo-Studien.
Ergebnisse: Die meisten Adsorber wurden zur Zytokin- und Endotoxinentfernung im Rahmen der Sepsis entwickelt. Bisher konnte aber keine randomisierte kontrollierte Studie (RCT) einen Überlebensvorteil durch den Einsatz von Hämoperfusion zeigen. Die S3-Leitlinie zur Therapie der Sepsis und die Leitlinie der Surviving Sepsis Campaign (SSC) raten deswegen von der routinemäßigen Anwendung ab. Zu Beginn der Coronapandemie wurde die Hämoperfusion als vielversprechender Therapieansatz gehandelt. Aktuelle Daten zeigen allerdings keine positiven Ergebnisse, sodass der Einsatz nicht routinemäßig empfohlen werden kann. Die Anwendung von Adsorptionsverfahren bei PatientInnen mit Leberversagen und Rhabdomyolyse ist nur rudimentär untersucht, sodass aktuell keine Empfehlung für oder gegen einen Einsatz ausgesprochen werden kann. Auch im operativen Setting (v. a. Herzchirurgie) und für die Elimination unerwünschter Medikamente gibt es keine ausreichende Evidenz, um die Anwendung regelhaft zu empfehlen.
Diskussion: Diverse Adsorptionsverfahren können verschiedene Stoffe eliminieren. Aktuell fehlen für alle Indikationen und Systeme Nachweise, die den routinemäßigen Einsatz fernab klinischer Studien rechtfertigen.
Keywords: Adsorption; Blood purification; Liver failure; Rhabdomyolysis; Sepsis.
© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.