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Li C, Zhang J, Yang P, Wang R, Chen T, Li L. The role of polymyxin B-immobilized hemoperfusion in reducing mortality and enhancing hemodynamics in patients with sepsis and septic shock: A systematic review and meta-analysis. Heliyon 2024; 10:e33735. [PMID: 39040355 PMCID: PMC11261863 DOI: 10.1016/j.heliyon.2024.e33735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/17/2024] [Accepted: 06/26/2024] [Indexed: 07/24/2024] Open
Abstract
Purpose Polymyxin B-immobilized hemoperfusion (PMX-HP) is a therapeutic strategy for removing circulating endotoxins from patients with sepsis or septic shock. However, the survival advantage of PMX-HP treatment remains controversial for patients with sepsis/septic shock. Therefore, this study collected all the clinical trials to assess the effect and the safety of PMX-HP treatment. Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for eligible trials fromtheir inception through June 30, 2023. All clinical trials that investigated the effect of polymyxin B hemoperfusion in patients who died with sepsis or septic shock within 28-day mortality were eligible. The Cochrane Risk of Bias Assessment instrument and the ROBINS-I tool were used to assess the risk of bias. Results A total of 30 trials, including 25680 adult patients, were included. PMX-HP decreased 28-day mortality (OR 0.75, 95 % CI 0.65-0.88; p<0.00001). Subgroup analysis revealed that 28-day mortality was significantly reduced after PMX-HP treatment in the mixed infection site group and in the age under 70 years old group. PMX-HP might also lower endotoxin levels (MD -1.22, 95 % CI -1.62 - 0.81, p < 0.00001) and improve SOFA scores (MD -2.11, 95 % CI -3.80- 0.43, p = 0.01). PMX-HP was not linked to the development of significant adverse events (p = 0. 05). Conclusion Our findings suggest that PMX-HP therapy can reduce 28-day mortality in individuals with sepsis or septic shock. The therapeutic effect may be due to the ability of PMX-HP to lower endotoxin levels and enhance hemodynamics. However, further assessment of the clinical effects of PMX-HP on sepsis or septic shock is required.
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Affiliation(s)
- Chao Li
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinlian Zhang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ranran Wang
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Chen
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lixia Li
- Department of Clinical Pharmacy, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Girardis M, Coloretti I, Antonelli M, Berlot G, Busani S, Cortegiani A, De Pascale G, De Rosa FG, De Rosa S, Donadello K, Donati A, Forfori F, Giannella M, Grasselli G, Montrucchio G, Oliva A, Pasero D, Piazza O, Romagnoli S, Tascini C, Viaggi B, Tumbarello M, Viale P. Adjunctive immunotherapeutic agents in patients with sepsis and septic shock: a multidisciplinary consensus of 23. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:28. [PMID: 38689337 PMCID: PMC11059820 DOI: 10.1186/s44158-024-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. METHODS A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. RESULTS The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. CONCLUSIONS Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.
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Affiliation(s)
- Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Antonelli
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Gennaro De Pascale
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia De Rosa
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, and Anesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, Departement of Anesthesia, Resuscitation and Emergency Torino, University of Turin, Turin, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Ornella Piazza
- University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Stefano Romagnoli
- Department of Health Science, Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Bruno Viaggi
- Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mario Tumbarello
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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3
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Falagas ME, Kyriakidou M, Voulgaris GL, Vokos F, Politi S, Kechagias KS. Clinical use of intravenous polymyxin B for the treatment of patients with multidrug-resistant Gram-negative bacterial infections: An evaluation of the current evidence. J Glob Antimicrob Resist 2021; 24:342-359. [PMID: 33486122 DOI: 10.1016/j.jgar.2020.12.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The epidemic dimensions of the emergence of multidrug-resistant (MDR) Gram-negative bacterial infections have led to the revival of old antibiotics, including the polymyxins. METHODS We performed a review and meta-analysis to evaluate the current literature data regarding the effectiveness and safety of intravenous polymyxin B in patients with MDR Gram-negative bacterial infections and the overall mortality and nephrotoxicity in patients treated with intravenous polymyxin B either as monotherapy or combination therapy. RESULTS A total of 5 prospective and 28 retrospective studies, 1 cross-sectional study, 2 retrospective case series and 7 case reports provided data regarding the effectiveness and/or toxicity of intravenous polymyxin B. All-cause mortality of 2910 patients (from 27 studies) who received intravenous polymyxin B was 41.2% (95% CI 35.5-47.0%). All-cause nephrotoxicity of 2994 patients (from 28 studies) treated with intravenous polymyxin B was 40.7% (95% CI 35.0-46.6%). Renal failure among 2111 patients (from 14 studies) was 11.2% (95% CI 8.7-13.9%). CONCLUSION Mortality of patients treated with intravenous polymyxin B is similar to the literature-reported mortality of patients treated with intravenous colistin, while nephrotoxicity associated with polymyxin B use is possibly milder compared with colistin use based on literature data. Head-to-head prospective studies would help to clarify the benefit of polymyxin B over colistin. However, a critical evaluation of the existing worldwide literature data supports the need for availability of the intravenous formulation of polymyxin B as a potentially useful option for the treatment of patients with MDR and extensively drug-resistant (XDR) Gram-negative bacterial infections.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece; Department of Medicine, Henry Dunant Hospital Center, Athens, Greece; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Margarita Kyriakidou
- Alfa Institute of Biomedical Sciences, Athens, Greece; School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
| | - Georgios L Voulgaris
- Alfa Institute of Biomedical Sciences, Athens, Greece; Laboratory of Pharmacokinetics and Toxicology, Department of Pharmacy, 401 General Military Hospital, Athens, Greece
| | - Filippos Vokos
- School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
| | - Sevasti Politi
- School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
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Shima H, Kimura T, Nishiuchi T, Iwase T, Hashizume S, Takamori N, Harada M, Higashiguchi Y, Masaki C, Banno T, Nagasaka N, Ito A, Inoue T, Tashiro M, Nishitani M, Kawahara K, Okada K, Minakuchi J. Successful treatment of direct hemoperfusion with polymyxin B-immobilized fiber for septic shock and severe acute kidney injury due to ceftriaxone-resistant Escherichia coli: a case report with literature review. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-00266-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Septic shock is a life-threatening condition and one of the most common causes of acute kidney injury. Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is used to reduce endotoxin levels in blood. Here, we report a rare but important case of sepsis-induced acute kidney injury and septic shock, which was successfully treated with PMX-DHP in spite of inappropriate initial antibiotic therapy.
Case presentation
An 84-year-old man was hospitalized for septic shock and acute kidney injury. Although he was treated with ceftriaxone, he did not recover from hypotension and had reduced urine output. After initiating PMX-DHP on days 3 and 4, his blood pressure was immediately elevated and his white blood cell count and C-reactive protein levels improved. Because ceftriaxone-resistant Escherichia coli was identified in blood culture, we changed his antibiotics to levofloxacin on day 7. He successfully recovered from the septic shock and dialysis was withdrawn.
Conclusions
Considering the use of inappropriate initial antibiotics, the early induction of PMX-DHP might have been a key determinant of his outcome. PMX-DHP therapy should be considered in septic shock in addition to antibiotic treatment.
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5
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Abstract
Sepsis is the primary cause of acute kidney injury in critically ill patients. During the past decades, several extracorporeal blood purification techniques have been developed for sepsis and sepsis-induced acute kidney injury management. These therapies could act on both the infectious agent itself and the host immune response. In this article, we review the available literature discussing the different extracorporeal blood purification techniques, including high-volume hemofiltration, cascade hemofiltration, hemoperfusion, coupled plasma filtration adsorption, plasma exchange, and specific optimized renal replacement therapy membranes.
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Affiliation(s)
- Thibaut Girardot
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France.
| | - Antoine Schneider
- Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA 7426 PI3 (Pathophysiology of Injury‑Induced Immunosuppression), Claude Bernard University Lyon 1, Biomérieux, Hospices Civils de Lyon, Lyon, France
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6
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Kinoshita M, Nakashima M, Nakashima H, Seki S. Immune Mechanisms Underlying Susceptibility to Endotoxin Shock in Aged Hosts: Implication in Age-Augmented Generalized Shwartzman Reaction. Int J Mol Sci 2019; 20:ijms20133260. [PMID: 31269748 PMCID: PMC6651521 DOI: 10.3390/ijms20133260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/01/2019] [Accepted: 07/01/2019] [Indexed: 01/20/2023] Open
Abstract
In recent decades, the elderly population has been rapidly increasing in many countries. Such patients are susceptible to Gram-negative septic shock, namely endotoxin shock. Mortality due to endotoxin shock remains high despite recent advances in medical care. The generalized Shwartzman reaction is well recognized as an experimental endotoxin shock. Aged mice are similarly susceptible to the generalized Shwartzman reaction and show an increased mortality accompanied by the enhanced production of tumor necrosis factor (TNF). Consistent with the findings in the murine model, the in vitro Shwartzman reaction-like response is also age-dependently augmented in human peripheral blood mononuclear cells, as assessed by enhanced TNF production. Interestingly, age-dependently increased innate lymphocytes with T cell receptor-that intermediate expression, such as that of CD8+CD122+T cells in mice and CD57+T cells in humans, may collaborate with macrophages and induce the exacerbation of the Shwartzman reaction in elderly individuals. However, endotoxin tolerance in mice, which resembles a mirror phenomenon of the generalized Shwartzman reaction, drastically reduces the TNF production of macrophages while strongly activating their bactericidal activity in infection. Importantly, this effect can be induced in aged mice. The safe induction of endotoxin tolerance may be a potential therapeutic strategy for refractory septic shock in elderly patients.
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Affiliation(s)
- Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
| | - Masahiro Nakashima
- Department of Immunology and Microbiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Hiroyuki Nakashima
- Department of Immunology and Microbiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
| | - Shuhji Seki
- Department of Immunology and Microbiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
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7
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Vorobii M, Kostina NY, Rahimi K, Grama S, Söder D, Pop-Georgievski O, Sturcova A, Horak D, Grottke O, Singh S, Rodriguez-Emmenegger C. Antifouling Microparticles To Scavenge Lipopolysaccharide from Human Blood Plasma. Biomacromolecules 2019; 20:959-968. [DOI: 10.1021/acs.biomac.8b01583] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mariia Vorobii
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
| | - Nina Yu. Kostina
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
| | - Khosrow Rahimi
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
| | - Silvia Grama
- Institute of Macromolecular Chemistry, Czech Academy of Sciences, Heyrovského nám. 2, 16206 Prague, Czech Republic
| | - Dominik Söder
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
| | - Ognen Pop-Georgievski
- Institute of Macromolecular Chemistry, Czech Academy of Sciences, Heyrovského nám. 2, 16206 Prague, Czech Republic
| | - Adriana Sturcova
- Institute of Macromolecular Chemistry, Czech Academy of Sciences, Heyrovského nám. 2, 16206 Prague, Czech Republic
| | - Daniel Horak
- Institute of Macromolecular Chemistry, Czech Academy of Sciences, Heyrovského nám. 2, 16206 Prague, Czech Republic
| | - Oliver Grottke
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Smriti Singh
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
| | - Cesar Rodriguez-Emmenegger
- DWI−Leibniz Institute for Interactive Materials and Institute
of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstrasse 50, 52074 Aachen, Germany
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8
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Iba T, Fowler L. Is polymyxin B-immobilized fiber column ineffective for septic shock? A discussion on the press release for EUPHRATES trial. J Intensive Care 2017; 5:40. [PMID: 28690852 PMCID: PMC5496228 DOI: 10.1186/s40560-017-0236-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 12/26/2022] Open
Abstract
The efficacy of polymyxin B-immobilized (PMX) fiber column on septic shock is still under debate. Recently, the result from "Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock (EUPHRATES)" trial has been announced as a press release. According to that report, less than a 5% mortality difference was recognized in the "per protocol population" (n = 244, 31.9 vs. 36.9%) and the decrease was not statistically significant. However, among the patients in refractory shock with a multiple organ dysfunction score of more than 9 and an EAA between 0.6 and 0.9, a 10.7% reduction in 28-day mortality was recognized (p = 0.0474) when they received two sessions of hemoperfusion using the PMX fiber column. Since this favorable effect was obtained from "post hoc" analysis, further study is expected.
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Affiliation(s)
- Toshiaki Iba
- Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Lucy Fowler
- Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan.,University of Birmingham, Birmingham, UK
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