Effectiveness And Safety Of Blood Purification Therapy In Patients With Sepsis:A Systematic Review

Background:Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.Some scholars have proposed that the imbalance of immune response in patients with sepsis might induce the release of a large number of inflammatory factors,which may be an important factor in the development of the disease.Blood purification can improve the therapeutic effect of sepsis by reducing the peak concentration of inflammatory factors in vivo via removing inflammatory mediators,but its efficacy and safety are still controversial.Objective:To explore whether blood purification therapy can improve the efficacy of sepsis by reducing the level of inflammatory markers,and to evaluate its potential risks.Materials and Methods:We searched the literature by electronic data of the Cochrane Library,Pub Med,EMbase,CNKI,CBM,VIP,Wan Fang up to March31,2020 to collect the randomized controlled trials on the effectiveness and safety of blood purification therapy for sepsis.These studies must include the changes in inflammatory markers before and after treatment.The primary end point was mortality at the end of follow-up,and the secondary end points includes APACHE II score,SOFA score,Oxygenation index.The safety evaluation index includes all kinds of adverse events and serious adverse events.Two researchers selected literature andextracted data according to inclusion and exclusion criteria.Different opinions were settled through discussion or being judged by another researcher.The quality ofthe included literature was evaluated according to the relevant methods of the Cochrane collaboration.Rev Man 5.3 software was used for statistical analysis.If the indicator could be analyzed in combination that was performed on Meta analysis,if not,we used descriptive methods.We used the fixed effect model to analyze the results of several studies with good homogeneity,For indicators with significant statistical heterogeneity(P<0.10,I~2≥50%)was analyzed by the random effect model.And we used subgroup analysis and sensitivity analysis to explore the sources of heterogeneity.Publication bias was assessed by visually inspecting funnel plots.Results:19 studies and 973 patients(491 cases in blood purification therapy and 482 cases in conventional therapy)were included in the analysis.Quality of the literature:0 low risk of bias,16 uncertain risk of bias,3 High risk of bias.The main problem is undescribed exit and loss of follow-up.19 RCTs showed that blood purification therapy could decrease the mortality[RR=0.82,95%CI(0.70 to 0.97),P=0.02,very low certainty evidence].6 RCTs showed that blood purification therapy could decrease APACHE II score[SMD=-0.90,95%CI(-1.12 to-0.68),P<0.00001,very low certainty evidence].6 RCTs showed that blood purification therapy could decrease SOFA score[MD=-2.63,95%CI(-3.31 to-1.95),P<0.00001,very low certainty evidence].5 RCTs showed that blood purification therapy could not decrease oxygenation index[SMD=0.74,95%CI(-0.29 to 1.77),P=0.16,very low certainty evidence].In the indifference group,6 RCTs showed that blood purification therapy did not decrease inflammatory mediators and mortality[RR=1.21,95%CI(0.94to 1.56),P=0.13,low certainty evidence].1 RCT showed that blood purification therapy did not decrease inflammatory mediators and SOFA score[MD=1.24,95%CI(0.78 to 1.97),P=0.36].1 RCT showed that blood purification therapy did not decrease inflammatory mediators but increased oxygenation index[SMD=2.43,95%CI(1.82 to 3.03),P<0.00001].In the drop group,13 RCTs showed that the blood purification therapy could decrease inflammatory mediators and mortality[RR=0.61,95%CI(0.49 to0.72),P<0.00001,very low certainty evidence].6 RCTs showed that blood purification therapy could decrease inflammatory mediators and APACHE II score[SMD=-0.90,95%CI(-1.12 to-0.68),P<0.00001,very low certainty evidence].6 RCTs showed that blood purification therapy could decrease inflammatory mediators and SOFA score[SMD=-2.63,95%CI(-3.31 to-1.95),P<0.00001,very low certainty evidence].4 RCTs showed that blood purification therapy could decrease inflammatory mediators and increased oxygenation index[SMD=1.19,95%CI(0.32 to 2.06),P=0.008,very low certainty evidence].safety analysis:13 RCTs reported adverse events and complications.The adverse events reported by the two groups were secondary infection,electrolyte disturbance,hypotension,pleural effusion,thrombocytopenia,anemia,fluid overload.Adverse event showed that 219 cases in experimental group and 228cases in control group.Serious adverse event showed that 36 cases in experimental group and 19 cases in control group.Adverse events related to blood purification therapy were as follows:fever in 3 cases(4.3%),blood clot in5 cases(10.9%),femoral artery injury causedby puncture in 1 case(8.3%),equipment related was 17.1%.Conclusion:Blood purification therapy can reduce the level of plasma inflammatory mediators and improve the therapeutic effect in sepsis,but it increases the incidence of treatment-related complications or adverse events.In view of the low quality of the included literature,there is still no strong evidence that blood purification therapy aimed at improving the efficacy of sepsis can be used routinely.Future clinical trials designed to target the possible effective mechanism of action and potential risks of blood purification therapy in the treatment of sepsis.