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Hemoperfusion
Dr. Vinant Bhargava DNB( Nephrology)
Consultant
Institute of Renal Science
Sir Gangaram Hospital, New Delhi
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History
Physical properties of hemoperfusion
Indications
Types of therapies and comparison
Complications
Summary
Index case 1
• 25/M , Farmer, No comorbities
• Alleged substance intake
• On presentation
– Comatose
– Hypotension
– Bradycardia
– Oliguria(8 hrs)
– Tachypnea
How will we manage this gentleman?
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Charcoal hemoperfusion
Resin based hemoperfusion
Hemodialysis only
CVVHD (F) plus hemoperfusion
Hemodialysis plus hemoperfusion
Index case 2
• 67/F, Diabetes Mellitus(20 yrs), Hypertension(5 years)
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Fever (8 days)
Stuporous (12 hrs)
Oliguria (4 hrs)
Jaundice(2 days)
• Hospital course
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Ventilated
Inotropic support(12 hrs)
Consolidation in the right middle lobe
Urine infection ( Klebsiella sp)
ABG: metabolic acidosis, hyperkalemia
How will we manage this pleasant lady?
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Charcoal hemoperfusion
Resin based hemoperfusion
Hemodialysis only
CVVHD (F) plus hemoperfusion
Hemodialysis plus hemoperfusion
History
- 1948: Muirhead and Reid killed several lab animals.
- Cation and anion exchange resin filters shown to remove 3.5gm
urea
- 1958: Schreiner
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removed a useful amount of pentobarbital out of an overdose
patient with 2 x 15-minute sessions on a lactated anion resin
column.
- 1964: Yatzidis et al
- treated barbiturate overdoses with coconut shell charcoal
- 1973: Chang et al
- demonstrate that though uremic toxin removal is greater with
hemoperfusion than with hemodialysis, urea itself could not be
removed in clinically useful quantities
- 1990: endotoxin removal
Physical principles(Hemoperfusion)
• Adsorption of chemicals.
– Activated charcoal, drugs are irreversibly bound via
van der Waals forces.
– Resins, drugs are not irreversibly bound and can be
eluted with organic solvents.
• Water- and lipid-soluble substances with
molecular weights ranging from 100 to 40,000
daltons are well adsorbed with hemoperfusion.
• Chemicals at higher molecular weights are
adsorbed less efficiently to polymer-coated
charcoal
J Biomed Mater Res. 1975;9(2):143.
Mechanism of adsorption
Mechanism Contd....
Methodology(Hemoperfusion)
• Hemoperfusion is conducted using
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dialysis blood lines,
a blood pump,
pressure gauges, and
a column that contains between 100 and 300 g of
activated charcoal or 300 to 650 g of resin.
• Heparin requirements are similar to hemodialysis
• Performed for three to four hours.
– Reuse of devices is not performed
• Efficient drug removal occurs with blood flow
rates of approximately 300 mL/min
Efficacy of Hemoperfusion in poisoning
• Animal models
– hemoperfusion increases drug elimination rates of
acetaminophen, amobarbital, ethchlorvynol, doxorubicin,
digoxin, and digitoxin.
– rebound of drug concentration occurs following
hemoperfusion.
• Human experience(international working group
(Extracorporeal Treatments in Poisoning [EXTRIP])
– Does not support except in case of severe intoxication
Clin Toxicol (Phila). 2012 Jun;50(5):403-13
Criteria for considering hemoperfusion
• Poisoning
– Progressive deterioration despite intensive supportive
therapy
– Severe intoxication with depression of midbrain function,
thereby leading to hypoventilation, hypothermia, and
hypotension
– Development of complications of coma, such as
pneumonia or septicemia
– Impairment of normal drug excretory function due to
hepatic, cardiac, or renal insufficiency.
– Intoxication with agents with metabolic and/or delayed
effects, such as paraquat
Trans Am Soc Artif Intern Organ. 1967; 13:369
WELL ESTABLISHED INDICATIONS
for hemoperfusion
PARAQUAT
- Near-continuous charcoal hemoperfusion
prevents progression to pulmonary fibrosis and
improves mortality
ORGANOPHOSPHATES
- Indicated in SEVERE massive overdose
- less beneficial in mild overdose
CARBAMAZEPINE
- Indicated in SEVERE massive overdose
THEOPHYLLINE
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Charcoal hemoperfusion decreases progression to
seizures and improves mortality
Holubek et al, Use of hemodialysis and hemoperfusion in poisoned patients idney International (2008) 74, 1327–1334;
Winchester, JF, Boldur, A, Oleru, C, Kitiyakara, C. Use of dialysis and hemoperfusion in treatment of poisoning. In: Handbook of Dialysis, 4th ed,
Daugirdas, JT, Blake, PG, Ing, TS (Eds), Lippincott Willliams & Wilkins, Philadelphia 2007. p. 300.
Replacement of renal function by dialysis: a textbook of dialysis By John Francis Maher, the 20th chapter by james F. Winchester (pp 439)
Pilapil M, Petersen J. Efficacy of hemodialysis and charcoal hemoperfusion in carbamazepine overdose. Clin Toxicol (Phila) 2008;46:342-3.
LESS WELL ETABLISHED APPLICATIONS
of hemoperfusion
- Methotrexate
- Better with uncoated charcoal
- Diltiazem
- Especially sustained release
- Phenytoin
- Half life reduced from 100 to 7 hrs
- Valproate
- Chloramphenicol in children
- Muscarine (from Amanita Muscaria)
Parish RC, Treatment of Amanita mushroom poisoning: a review. Vet Hum Toxicol. 1986 Aug;28(4):318-22.
Grafft et al, High-dose continuous venovenous hemofiltration combined with charcoal hemoperfusion for methotrexate removal NDT Plus (2011) 4 (2): 87-89
Greenberg et al, Severe theophylline toxicity: Role of conservative measures, antiarrhythmic agents, and charcoal hemoperfusion The American Journal of
Medicine Volume 76, Issue 5 , Pages 854-860, May 1984
Molina, Fabian, et al; Use of charcoal hemoperfusion to reduce serum methotrexate levels in a patient with acute renal insufficiency Am J Med 82: 350, 1987
Roberts et al, Lessons learnt in the pharmacokinetic analysis of the effect of haemoperfusion for acute overdose with sustained-release diltiazem Anaesthesia
Volume 63, Issue 7, pages 714–718, July 2008
Eyer F, Felgenhauer N, Pfab R, Thürmel K, Zilker T. Treatment of severe intravenous phenytoin overdose with hemodialysis and hemoperfusion. Med Sci
Monit. 2008 Dec;14(12):CS145-8.
Licari, Elisa MD; Calzavacca, Paolo MD; Warrillow, Stephen J. MD; Bellomo, Rinaldo MD Life-threatening sodium valproate overdose: A comparison of two
approaches to treatment. Critical Care Medicine: December 2009 - Volume 37 - Issue 12 - pp 3161-3164
Charcoal Hemoperfusion
in Hepatic Encephalopathy
in 1972, Chang et al first reported the use of charcoal hemoperfusion in an
encephalopathic woman. (She survived)
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In theory, the mercaptans and ammonia are adsorbed more easily than they are dialysed
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The idea is to intervene BEFORE Stage IV coma by West Haven Criteria
(i.e. before unresponsiveness, when cerebral oedema is irreversibly established)
Exactly when to intervene?
Nobody agrees.
Some useful things may also be removed.
Studies of Hemoperfusion
in hepatic encephalopathy
• From 1972 to 1985:
• as methodology improved,
treatment effect deteriorated
Treatment effect may be owed
more to cessation of the agent or
condition which is responsible for the
induction of the coma.
Opinion of experts:
- Nobody knows at what stage to start HP
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Everyone seems to agree that resin
rather than charcoal should be used
(as not all molecules responsible for
encephalopathy are removed)
Non standard indications for hemoperfusion
1976, McEwoy et al
Psoriasis improved during dialysis. Effect was not sustained in RCT.
1977, Wagemaker and Cade:
“dramatic” improvement in delusions and paranoid ideation in 5 out of the 6 chronic
schizophrenics , attributed to the hemoperfusion removal of leucine-endorphin.
Not supported by subsequent series.
2009, EUPHAS trial:
Significant reduction in mortality following hemoperfusion with Polymyxin-B containing column, in 64
surgical patients with severe septic shock.
Trial terminated: unethical to withhold lifesaving polymyxin.
Aluminium toxicity:
In conjunction with chelating agents (deferoxamine)
Uremic pruritis: RCT confirms utility
Toxic epidermolysis necrolysis
Wagemaker, Cade ; the use of hemodialysis in chronic schizophrenia. Am J Psychiatr 134: 684 1977.
McEwoy et al, psoriatic clearance during hemodialysis Ulster Med J 76: 1976
Cruz DN, Antonelli M, Fumagalli R, et al. Early Use of Polymyxin B Hemoperfusion in Abdominal Septic Shock: The EUPHAS
Randomized Controlled Trial JAMA. 2009;301:2445-2452
Medicine (Baltimore). 2017 Mar;96(12):e6160, J Dermatolog Treat. 2016 Oct 24:1-7
Other Indications for Hemoperfusion
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SLE
Rheumatoid arthritis
HLA antibodies removal
ABO incompatible transplants
– Glycosorb column
– Adsopak column
No
randomised
controlled
trials
Hemoperfusion for Metabolic Disturbance
 Disorders characterized by loss of metabolic balance, featuring liver and
kidney failure
 Examples:
– Inborn errors of metabolism (e.g., PKU)
– Type I diabetes
– Gaucher disease
– Thyroid disease
 Symptoms: Respiratory difficulty, altered mental status, seizures, organ failure.
Shi and Chang, Int J Artif Organs, 1984 Showed that HP significantly reduced
various amino acids in rats
• Horky et al, Czech Med, 1981: Showed that HP effectively removed various
substances (phenols, urate) in 7/9 patients with metabolic disorders with
minimal adverse events
Metabolic disturbance
• No studies were identified with the criteria for this literature
review
• Therefore, for this indication, there is insufficient evidence
that sorbent hemoperfusion systems are safe and effective
Available hemoperfusion devices
Manufactur
er
Device
Sorbent
type
Asahi
Hemosorba
Spherical
charcoal
Gambro
Adsorba
Toray
Industries
Cytosorbents
Amount of
sorbent
170 g
Polymer
coating
Cost
Polyhema
14,000
Norit charcoal 100 or 300 g
Cellulose
acetate
12,800
Toraymyxin*
Toraymycin
None
1,08,000
Cytosorb*
Polystyrene
300 g
divinylbenzen
e copolymer
None
77,500
?
Hemodialysis versus hemoperfusion
• Hemoperfusion is preferred to hemodialysis for the removal of
chemicals that are lipid soluble or are highly protein bound.
• Hemodialysis is preferred for water soluble low-molecularweight compounds since these compounds readily cross
hemodialysis membranes.
• With the advent of high-flux dialysis membranes for routine
hemodialysis
– high-flux membrane drug removal may be equal to that of
hemoperfusion
Med J Malaysia. 2006;61(1):109
Nephron. 2002;90(2):213
Hemodialysis versus hemoperfusion
• Advantages :
– removes the toxic metabolites of methanol and ethylene glycol
– Corrects Electrolyte disturbances and metabolic acidosis (drugs)
– High clearance relative to total body clearance
• Disadvantages :
– Low molecular weight (<500 daltons)
– Low degree of protein-binding
– Small volume of distribution (<1 L/kg)
– Low endogenous clearance (<4 mL/min per kg)
Handbook of Dialysis, 4th ed., Daugirdas JT, Blake PG, Ing TS (Eds), Lippincott Williams & Wilkins, Philadelphia 2007. p.300.
Hemodialysis+ Hemoperfusion
• Hemodialysis
– can remove only substances that are highly diffusable, non protein bound and with
small and middle-molecular weight.
• Charcoal hemoperfusion
– Removes uric acid, creatinine, middle molecules and other putative uremic toxins. In
this it is comparable to hemodialysis.
– Unlike hemodialysis it does not remove urea
• The combination of Hemodialysis-Hemoperfusion (HD-HF) takes advantage of both
techniques.
Hemoperfusion
• In contrast to HD circuits,
hemoperfusion devices
– contain thin, highly porous
membranes and adsorbents that
provide a large surface area to
directly bind toxins .
– Clearance rates are higher with
hemoperfusion than HD
– the extraction ratio for
hemoperfusion approximates 1.0
for some poisons.
– Hemoperfusion may be
considered for use in severe
poisoning from the toxins
Hemofiltration
• CVVHF,CVVHDF
•The evidence for these techniques is
scant.
• CRRT has lower clearance rates
than conventional HD.
•benefit for intoxications with drugs
that have a large volume of
distribution, tight tissue binding, or
slow intercompartmental transfer
• It might offer some benefit in
unstable or hypotensive patients .
Contraindications
Complications
– HD and hemoperfusion
normally require systemic
anticoagulation with heparin,
and patients with active
hemorrhage, severe
thrombocytopenia, or
coagulopathy may not be
candidates for these
procedures.
– HD and hemoperfusion may
not be feasible in hypotensive
patients.
• Hemodialysis
•Hypotension, bleeding due to
anticoagulation, hypothermia,
air embolus
•complications that may result
from obtaining central venous
access .
•Hemoperfusion
•charcoal embolization,
hypocalcemia, hypoglycemia,
•Leukopenia ( 10 percent
reduction)
•Thrombocytopenia (30 percent
reduction).
The Charcoal Hemoperfusion Filter
- Canister with 300g of
activated charcoal
- Blood flow though the
canister is driven by a
normal dialysis machine
- There is no ultrafiltration,
no fluid removal,
no dialysis.
Brochure from the “Adsorba C” range by Gambro, for the Prismaflex machines
Complications of Charcoal Hemoperfusion
EARLY PROBLEMS
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Particle embolization in filters with uncontrolled granule diameter
Profound platelet depletion with uncoated filters
Anaphylactic reactions to dirty coconut charcoal
Deposition of hydrocarbons into the patient by treated charcoal
PROBLEMS REMAINING
- Some platelet depletion with coated filters
- Fibrinogen depletion
- Leucopenia: complement is activated even by coated filters, and this
results in leucocyte margination
- Hypotension: due to platelet activation in the filter, and resulting
massive release of vasoactive amines
- Removal of calcium
- Removal of glucose
- Removal of hormones, coagulation factors and trace elements
Devices designed to remove endotoxin and cytokines in sepsis.
Mediators of Inflammation Volume 2013, Article ID
507539
Toraymyxin consists of Polystyrene - based fiber to which
Polymyxin B is bound covalently (immobilized)
The surface of the fiber is
porous. Therefore, it
increases its surface area.
NH2
NH2
Polymyxin B
NH
NH2
NH2
CH2NHCOCH2Cl
Toraymyxin:(PMX-B DHP)
Endotoxin Binding without
Systemic Side Effects
CH2CH
CH2NHCOCH2Cl
CH2NHCOCH2
CH2CH
The endotoxin adsorbing
capacity of Toraymyxin was
found to be 64,000 ng
contained in bovine serum
CH2CH
Polystyrene derivative fiber
Sakai Y. et al.
Therapeutic Plasmapheresis (XII): 837-842, 1993
oXiris
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AN69 polyacrylonitrile hemofilter
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Additional surface treatment with polyethyleneimine (PEI) and lipid A
phosphate groups helps bind endotoxin.
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It is further grafted with heparin to reduce membrane thrombogenicity
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Surface adsorption is purely selective on endotoxin because of the
specific configuration of the membrane.
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The bulk adsorption is nonselective and can absorb numerous mediators
unselectively
oXiris
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SepteX
Therapy principle = Removal of cytokines by dialysis
Indications: Adjunctive sepsis therapy for cytokine removal
Machines to run: PrismafleX
Run mode: CVVHD
Treatment: for 48-72h, change of the membrane when diffusion performance drops
Anticoagulation: Heparin, Citrate
Available studies: Despite two RCT showing broad cytokine removal there is very limited
human data with the septeX membrane
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Hemoperfusion: FDA
Summary and
Recommendations
Hemoperfusion for Drug Overdose/Poisoning
• There are often no alternative therapies to hemoperfusion for the
removal of certain substances (e.g., paraquat).
• Studies show well-understood risks for hemoperfusion for these
indications.
• FDA believes that medical evidence strongly displays benefit over
risk, and that there is sufficient evidence to establish special
controls for drug overdose and poisoning.
FDA Recommendations
• The FDA recommends a split classification and the following revision to
Section §876.5870:
– For drug overdose/poisoning: Class II
– For hepatic coma and metabolic disturbances: Class III (premarket approval)
• FDA believes that special controls can be established to permit
reclassification of hemoperfusion for the treatment of drug
overdose/poisoning to Class II.
• FDA believes that adequate special controls cannot be established to
permit reclassification of hemoperfusion for the treatment of hepatic
coma and metabolic disturbances, and that these devices meet the
criteria for Class III devices for these indications.
Clinical studies
J Bras Nefrol 2010;32(4):340-348
Comparison of conventional hemodialysis
with charcoal hemoperfusion
Clearance of Drugs
Specialised adsorption resins
Botella et.al. Adsorption in hemodialysis. Kidney International (2000) 58, S60–S6
Clearance of
Drugs:
comparison of
conventional hemodialysis
with charcoal hemoperfusion
With charcoal,
at least a modest benefit
Botella et.al. Adsorption in hemodialysis. Kidney International (2000) 58, S60–S6
Blood purification & Mortality
Effects of hemodialysis and hemoperfusion on
inflammatory factors and nuclear transcription
factors in peripheral blood cell of multiple organ
dysfunction syndrome
OBJECTIVE: To investigate the effects of hemodialysis (HD) and hemoperfusion
(HP) on inflammatory factors and nuclear transcription factors in peripheral blood
cell of multiple organ dysfunction syndrome (MODS) patients.
PATIENTS AND METHODS:
• 92 cases of MODS
• Control group was treated with conventional hemodialysis(HD)
• Observation group was treated with hemoperfusion combined therapy
(HD+HP)
Parameters measured:
•serum creatinine (SCR), serum total cholesterol (TC), blood urea nitrogen
(BUN) and serum albumin (Alb)
• TNF-α and IL-6 in peripheral blood were detected between two group
European Review for Medical and Pharmacological Sciences 2016; 20: 745-750
Comparison of Scr, BUN, TC, Scr and Alb in two groups before and after treatment. A, Comparison
of Scr level; B, Comparison of TC level; C, Comparison of BUN level; D, Comparison of Alb level.
Effects of hemodialysis and hemoperfusion on inflammatory factors and
nuclear transcription factors
CONCLUSIONS: Hemodialysis combined with hemoperfusion in
treating MODS patients could significantly improve the biochemical
indicators, effectively remove the inflammatory mediums, and
significantly inhibit the activation of NK-κB.
European Review for Medical and Pharmacological Sciences 2016; 20: 745-750
ABDOMIX trial Toraymyxin
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Ongoing studies
EUPHAS2
EUPHAS2 is a prospective web-based registry of patients treated with
PMX-DHP designed to validate the reproducibility of randomized
clinical trial results and to observe the 'real world' efficacy and utility
of PMX-DHP therapy across a wider variety of patient populations
EUPHRATES
The EUPHRATES trial is a multi-centered, blinded, randomized
controlled trial of PMX-DHP in patients with septic shock and
confirmed endotoxemia using EAA greater than 0.60.
The trial is being conducted in 50 ICUs in the United States and Canada
oXiris – studies
Status August 2015
Source: https://www.clinicaltrials.gov/ct2/results?term=oxiris&Search=Search
48
septeX – studies
49
Status August 2015
Source: https://www.clinicaltrials.gov/ct2/results?term=septex&Search=Search
Different Extra Corporeal Therapies
Cytosorb
Indian data (Hemoperfusion)
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Single centre, observational studies
Case reports
Randomized controlled trials: Nil
Outcome
– Poisoning
• Industrial agents( pesticides, herbicides)
• Dugs(digoxin,metformin, phenytoin)
– Sepsis
• Inconclusive
SGRH experience(2000-2016)
• Number of patients: 164 (poisoning)
– Hemoperfusion alone: 104
– Hemoperfusion plus Hemodialysis: 48
– Hemodialysis ( high flux): 12
• Outcomes
– Patient mortality:
• Hemoperfusion alone: 42/104(40%)
• Hemoperfusion plus hemodialysis: 23/48( 48%)
• Hemodialysis alone: 7/12( 58%)
• Complications:
– Thrombocytopenia
– Hypoglycemia
– Hypocalcemia
Summary
• Hemoperfusion is preferred to hemodialysis for the removal
of chemicals that are lipid soluble or are highly protein
bound(paraquat, mushroom).
• Hemodialysis is preferred for water-soluble, low-molecular
weight compounds.
• In humans, in view of the difficulties in conducting controlled
prospective clinical trials
– a reduction in coma time or overall mortality has not been
conclusively demonstrated with hemoperfusion
Summary
• Hemoperfusion combined with hemodialysis is a promising
option in patients with MODS and sepsis.
• Concurrent hemodialysis and hemoperfusion is a safe option
in poisoning patients.
• Hemofiltration has a role only in patients with severe
hypotension and in poisoning agents with large volume of
distribution.
Thank you
Prolonged direct hemoperfusion using a polymyxin B
immobilized fiber cartridge provides sustained
circulatory stabilization in patients with septic shock: a
retrospective observational before-after study
Methods:
• Retrospective study
• Compared the effects of prolonged and conventional PMX-DHP
durations (2 and12 h) for septic shock.
• 18 patients underwent conventional PMX-DHP, and
• 18 patients underwent prolonged PMX-DHP.
Primary outcome: vasopressor dependency index
Miyamoto et al. Journal of Intensive Care (2017) 5:19
Vasopressor
dependency index
•
The conventional PMX-DHP group had vasopressor dependency index values
of 0.52 ± 0.29 and 0.39 ± 0.25 at 0 and 12 h after starting PMX-DHP.
•
The prolonged PMX-DHP group had vasopressor dependency index values of
0.50 ± 0.26 and 0.28 ± 0.18 at 0 and12 h after starting PMX-DHP
Conclusions:
Findings suggest that prolonged PMX-DHP
provides more sustained circulatory stabilization
compared to conventional PMX-DHP.
Miyamoto et al. Journal of Intensive Care (2017) 5:19
FDA Assessment of Risks With Hemoperfusion
Risks Identified by Original Panel
Newly Identified Risks
Criteria for considering hemoperfusion
• Hepatic failure
– in which extraction of hepatic toxins may prevent or delay
hepatic coma
– serves as a bridge to hepatic transplantation
• End-stage renal disease with aluminum intoxication
– In conjunction with chelating agents (deferoxamine) to
remove aluminum
Eur J Gastroenterol Hepatol. 1997;9(4):407
Lancet. 1983;2(8358):1051
septeX - Procedure
62
septeX –Ongoing & planned studies
Honore PM et al. Newly Designed CRRT Membranes for Sepsis and SIRS-A Pragmatic Approach for Bedside
Intensivists Summarizing the More Recent Advances: A Systematic Structured Review. ASAIO J. 2013 Mar;59(2):99-106
65
Status August 2015
oXiris – studies
Honore PM et al. Newly Designed CRRT Membranes for Sepsis and SIRS-A Pragmatic Approach for
Bedside Intensivists Summarizing the More Recent Advances: A Systematic Structured Review.
ASAIO J. 2013 Mar;59(2):99-106
Status August 2015
66
oXiris
Therapy principle = Adsorption; Removal of endotoxin
Indications: Adjunctive sepsis therapy for gram-negative sepsis
Machines to run: PrismafleX
Run mode: The oXiris set can be used in any CRRT modality
Treatment: for 48-72h, change of the membrane when diffusion performance drops
Anticoagulation: Heparin, Citrate
Available studies: Very limited amount of studies. There is only one animal study in septic
pigs published. Human trials are totally missing so far.
67
•An activated Charcoal hemoperfusion device containing 300g
acrylic hydrogel coated activated charcoal was combined with
hemodialysis.
• Plasma clearance of both creatine and urate were increased
during combined hemodialysis-hemoperfusion period.
Creatinine clearance
in hemoperfusionhemodialysis
combined patient
Urate clearence in
hemoperfusionhemodialysis
combined patient
Change in platelet
count in
hemoperfusionhemodialysis
combined patient
Conclusion: Combined hemoperfusion and
hemodialysis can increase the efficacy of dialysis and
is not associated with unacceptable platelet depletion
Extraction ratios for some drugs and chemicals with hemodialysis,
charcoal hemoperfusion and resin hemoperfusion*
Cuprophane
hemodialysis
Coated OR
uncoated charcoal
hemoperfusion
XAD-2 or XAD-4
resin
hemoperfusion
Acetylsalicyclic acid 0.5
0.5
-
Digoxin
0.2
0.3 to 0.6
0.4
Glutethimide
0.16
0.65
0.8
Paraquat
0.5
0.6
0.9
0.27
0.5
0.85
Theophylline
0.5
0.7
0.75
Tricyclic
◊
antidepressants
0.35
0.35
0.8
Phenobarbital
Δ
¶
* Calculated for blood flow rate of 200 mL/min.
¶ Specially prepared ion-exchange resin.
Δ 0.36 to 0.47 with high-flux membranes.
◊ Large volume of distribution mitigates against removal of appreciable quantities of
©2017 UpToDate
drug.
Concurrent Hemoperfusion and Hemodialysis
in Patients with Acute Pesticide Intoxication
Blood Purif. 2016;42(4):329-336. Epub 2016 Oct 22
Water soluble and insoluble chemicals in the pesticide formulation
may be eliminated more effectively in time if hemodialysis (HD) and
hemoperfusion (HP) are performed concurrently.
AIM: Evaluating the efficacy of concurrent HP and HD in patients with
acute pesticide intoxication.
METHODS:
• Between Jan 2011 and Dec 2012, HP and HD were used
consecutively (HP-HD group, 347 cases),
• Next 2 years (Jan 2013 to Dec 2014),concurrent HP and HD were
used (HPD group, 383 cases).
RESULTS:
The mortality was higher in the HP-HD group than in the
HPD group: (48.1 vs. 20.9%) for the overall mortality
CONCLUSION:
• Concurrent HP and HD would be an effective and safe
treatment for patients with acute pesticide intoxication, in
particular, paraquat intoxication.
Hemoperfusion in
Overdose
Notable drugs:
-Theophylline
-Barbiturates
-Tricyclics (incl. Carbamazepine)
-Digoxin
-Salicylates
-Paraquat
-Organophosphates
Replacement of renal function by dialysis: a textbook of dialysis By John Francis Maher, the 20th chapter by james F. Winchester (pp 439)