The therapeutic efficacy of adjunct therapeutic plasma exchange for septic shock with multiple organ failure: a single-center experience

Abstract

Background: Sepsis remains a common condition with high mortality when multiple organ failure develops. The evidence for therapeutic plasma exchange (TPE) in this setting is promising but inconclusive. Our study aims to evaluate the efficacy of adjunct TPE for septic shock with multiple organ failure compared to standard therapy alone. Methods: A retrospective, observational chart review was performed, evaluating outcomes of patients with catecholamine-resistant septic shock and multiple organ failure in intensive care units at a tertiary care hospital in Winston-Salem, NC, from August 2015 to March 2019. Adult patients with catecholamine-resistant septic shock (≥ 2 vasopressors) and evidence of multiple organ failure were included. Patients who received adjunct TPE were identified and compared to patients who received standard care alone. A propensity score using age, gender, chronic co-morbidities (HTN, DM, CKD, COPD), APACHE II score, SOFA score, lactate level, and number of vasopressors was used to match patients, resulting in 40 patients in each arm. Results: The mean baseline APACHE II and SOFA scores were 32.5 and 14.3 in TPE patients versus 32.7 and 13.8 in control patients, respectively. The 28-day mortality rate was 40% in the TPE group versus 65% in the standard care group (p = 0.043). Improvements in baseline SOFA scores at 48 h were greater in the TPE group compared to standard care alone (p = 0.001), and patients receiving adjunct TPE had a more favorable fluid balance at 48 h (p = 0.01). Patients receiving adjunct TPE had longer ICU and hospital lengths of stay (p = 0.003 and p = 0.006, respectively). Conclusions: Our retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone. Hemodynamics, organ dysfunction, and fluid balance all improved with adjunct TPE, while lengths of stay were increased in survivors. The study design does not allow for a generalized statement of support for TPE in all cases of sepsis with multiple organ failure but offers valuable information for a prospective, randomized clinical trial.

A retrospective study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone: true effect or mediated by a negative fluid balance achieved by RRT?

“…We would like to make some comments. The authors reported that the patients who received adjunct TPE had a more favorable fluid balance at 48 h [1]. TPE is not able to induce a negative fluid balance.…”

“…The mortality associated with the new need for RRT was 48% in those receiving TPE compared to 79% in those receiving standard of care alone [1]. Almost 70% of the TPE+ patients required RRT versus only 50% of the patients in the standard of care group [1]. One of the most impressive results seen was the greater relative reduction in mortality among patients receiving TPE who had a primary sepsis diagnosis of pneumonia (pneumonia 11/23 TPE+ [mortality 47.8%] vs 15/17 TPE− [mortality 88.2%]), a situation where a negative fluid balance is so crucial [1].…”

“…We read with great interest the recent article by Keith et al who concluded that their retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct therapeutic plasma exchange (TPE) compared to standard care alone [1]. The 28-day mortality rate was 40% in the TPE group (TPE+) versus 65% in the standard care group (TPE−) [1]. We would like to make some comments.…”

“…TPE is not able to induce a negative fluid balance. Patients undergoing adjunct TPE required initiation of renal replacement therapy (RRT) in 67.6% of cases, compared to 51.4% in those receiving standard of care alone [1]. The mortality associated with the new need for RRT was 48% in those receiving TPE compared to 79% in those receiving standard of care alone [1].…”

“…Patients undergoing adjunct TPE required initiation of renal replacement therapy (RRT) in 67.6% of cases, compared to 51.4% in those receiving standard of care alone [1]. The mortality associated with the new need for RRT was 48% in those receiving TPE compared to 79% in those receiving standard of care alone [1]. Almost 70% of the TPE+ patients required RRT versus only 50% of the patients in the standard of care group [1].…”