Hemodynamic Effects of Therapeutic Plasma Exchange and High-Volume Hemofiltration in Refractory Septic Shock: A Systematic Review and Meta-Analysis

Azhzhilla Izza Mora Lubis, Nanda Andini, Ahmad Aziz Multazam

Abstract

Background : Early hemodynamic stabilization is crucial in refractory shock. NE dose reflects vasoplegia severity and vasopressor dependency. Therapeutic plasma exchange (TPE) and hemofiltration (HVHF) are adjuncts to facilitate down-titration. This meta-analysis compared TPE, HVHF, and standard of care (SOC) on NE dose and clinical outcomes.

Methods :  Analysis was performed using Review Manager software, and random- and fixed-effects models were used to calculate pooled estimates for the data.

Results : Both TPE and HVHF were associated with reductions in NE requirements in the overall analysis (TPE: MD −0.21, 95% CI −0.27 to −0.14, p < 0.00001; HVHF: MD −0.50, 95% CI −0.71 to −0.30, p < 0.00001), with a significant indirect subgroup difference (p = 0.006). Within 6 hours, the pooled NE reduction was significant (SMD −1.06, 95% CI −1.97 to −0.15; p = 0.02); TPE showed a significant reduction (SMD −1.91, 95% CI −2.67 to −1.15; p < 0.00001), whereas HVHF did not reach statistical significance (SMD −0.60, 95% CI −1.24 to 0.03; p = 0.06). No significant overall reduction was observed at 12 hours, whereas a significant pooled reduction was observed at 24 hours (SMD −1.54, 95% CI −3.02 to −0.07; p = 0.04); the HVHF estimate at 24 hours was derived from a single study. TPE significantly reduced stroke volume variation (SMD −0.90, 95% CI −1.29 to −0.51; p < 0.00001) and improved PaO₂/FiO₂ (SMD 2.41, 95% CI 0.22–4.61; p = 0.03). ICU-free, vasopressor-free, and RRT-free days were not significantly improved, whereas TPE was associated with lower 28-day mortality (RR 0.60, 95% CI 0.47–0.77; p < 0.0001).

Conclusion : Both TPE and HVHF were associated with reductions in vasopressor requirements, with different temporal patterns observed across indirect subgroup analyses. TPE was also associated with lower 28-day mortality; however, direct comparative evidence between the two modalities remains limited.

 

 

 

Keywords

Critical care; Norepinephrine; Refractory septic shock; Therapeutic plasma exchange; Vasopressor sparing

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DOI: https://doi.org/10.20961/soja.v6i2.117261

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