Survival Benefits of Therapeutic Plasma Exchange in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis

Abstract

Objectives To summarize the role of therapeutic plasma exchange (TPE) in critically ill adults and children with severe sepsis. Data collection A systematic search was performed using the following databases: Medline, EMBASE, CINAHL, and Cochrane from January 1990 till December 2022. Comparative studies of TPE in severe sepsis were selected. Adult and pediatric data were analyzed separately. Data synthesis Eight randomized control trials and 6 observational studies (n = 50,142 patients) were included. Centrifugal TPE was the most common modality (209/280, 74.6% adults and 952/1026, 92.7% children). Every TPE study utilized different volume exchanges. Most TPE sessions (1173/1306, 89.8%) employed fresh frozen plasma (FFP) as replacement fluid and heparin as anticoagulant. Adults with severe sepsis supported with TPE using FFP had lower mortality (risk ratio, RR: 0.64 [95% confidence interval, CI: 0.49, 0.84]) compared to those who did not. In contrast, TPE was associated with increased mortality in septic children without thrombocytopenia-associated multiorgan failure ( RR: 2.23, 95% CI: 1.93, 2.57). There was no difference in outcomes in patients supported with centrifugal and membrane TPE. In both populations, patients supported on TPE as a continuous regime had poorer outcome. Conclusion Current evidence indicates that TPE is a potential adjunct therapy in adults with severe sepsis but not in children.

Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis

“…Our meta-analysis demonstrates a significant reduction in short-term mortality when adjunct TPE is added to the standard therapy of critically ill patients with sepsis-induced organ dysfunction. These findings, combined with those of three recently published meta-analyses [66][67][68] add to the current body of evidence reflected in the 2023 ASFA guidelines which allow TPE to be considered on a case to case basis for sepsis with multiple organ dysfunction (category III, 2A recommendation) [41]. In addition, a large propensity-score matched analysis [69] demonstrating reduced 28-day and 1-year mortality associated with TPE in septic patients with MODS was published in November 2023, but was not included in the current analysis so as to avoid deviations from the predefined protocol and to avoid bias.…”

Managing sepsis and septic shock in an endothelial glycocalyx-friendly way: from the viewpoint of surviving sepsis campaign guidelines

“…Besides the above, plasma/FFP contains physiological oxidase, protease, and matrix metalloproteinase inhibitors that may help maintain the glycocalyx, and plasma/FFP decreases fluid requirements during resuscitation compared to crystalloids [ 36 ]. Recent studies report the beneficial effect of plasma exchange in severe sepsis and septic shock [ 37 ]. In an 80-patient pediatric trial of sepsis/septic shock in a non-overt DIC stage, early administration of FFP, low-dose heparin (LMWH), and tranexamic acid improved survival and prevented progression to overt disseminated intravascular coagulopathy (DIC), with no increased bleeding risk [ 38 ].…”

Enhancing Survival in Septic Shock: A Systematic Review and Meta-Analysis of the Efficacy of Plasma Exchange Therapy

“…In a large-scale review by Lee et al involving over 50,000 patients, adults with severe sepsis who underwent TPE with FFP showed lower mortality rates [ 20 ]. However, in septic children without thrombocytopenia-associated multiorgan failure, TPE was linked to higher mortality.…”