Do you filter for severe sepsis?

Todd Fraser on 10-01-2010

Its been part of our mantra for treating severe sepsis for 10 years or more now, to institute early aggressive haemofiltration in a patient with severe sepsis, with or without overt renal failure. The belief has been that haemofiltration can assist removal of the so-called "middle molecules" such as interleukins and cytokines. Recently Payen et al published data in Critical Care Medicine that suggests that not only does this not improve outcomes, it may actually HARM the patient. The data was originally collected in 1997-2000, and uses polysulphone membrane filters, now recognised to be least likely to be useful in this circumstance. This is the largest study in this area so far. Cole et found little difference in 2002 when they compared organ function and cytokine levels in patients treated with 2L exchanges. However others have found higher effluent rates may infact do so. However, outcome data for higher volume exchanges is lacking. So where does this leave us? Along with the recently released RENAL study, which showed higher effluent rates don't improve outcomes, where does the role of haemofiltration in sepsis stand? What do you do?

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AMIT KANSAL wrote 04-23-2010 11:08:50 pm
So, undoubtedly there is insufficient evidence to support high volume filtration.
I use filtration only for sepsis with established/ refractory renal failure, CVVHDF.
Cumulative evidence from RENAL/ VA-NIH studies would suggest dialysing enough but no need for more!

Todd Fraser wrote 05-18-2010 04:42:51 pm
Hmmmm.

I still find this quite difficult - how much renal failure is "enough" to require intervention, particularly in a patient with critical illness. How much does his ARF contribute to his haemodynamic instability? If we just got his acidosis under control, would he respond better to inotropes?