Original Investigations: Pathogenesis and Treatment
Endotoxin removal by direct hemoperfusion with an adsorbent column using polymyxin B-immobilized fiber ameliorates systemic circulatory disturbance in patients with septic shock,☆☆

https://doi.org/10.1053/ajkd.2002.32767Get rights and content

Abstract

Direct hemoperfusion (DHP) with an adsorbent column using polymyxin B-immobilized fiber (PMX-F) has been shown to improve the state of shock in patients with septic shock. However, no evidence has been presented for a direct link between endotoxin removal by DHP with PMX-F and improvement in septic shock. We retrospectively analyzed clinical profiles of 24 patients with septic shock (16 patients, gram-negative; 8 patients, non-gram-negative septic shock) who underwent DHP with PMX-F. Patients with gram-negative septic shock were characterized by hyperdynamic circulation. DHP with PMX-F reduced blood endotoxin concentrations and ameliorated shock, with an improvement in hyperdynamic circulation in patients with gram-negative septic shock. Mean arterial pressure also was elevated after therapy in patients with non-gram-negative septic shock, but systemic hemodynamics were unaffected. Regardless of the causative microorganism, patients with endotoxemia (blood endotoxin level > 10 pg/mL) showed hyperdynamic shock, and DHP with PMX-F reduced blood endotoxin levels and ameliorated hyperdynamic circulation, whereas patients without endotoxemia showed features of shock without hyperdynamic circulation, and DHP with PMX-F ameliorated shock without affecting cardiac performance. In patients with gram-negative septic shock, blood endotoxin concentration correlated positively with cardiac output and negatively with systemic vascular resistance before DHP therapy. Reduction in blood endotoxin concentration by DHP therapy positively correlated with the reduction in cardiac output. Our findings indicate that the improvement in hyperdynamic circulation was related directly to endotoxin removal by the PMX-F column, and endotoxin has an important role in the development of hyperdynamic circulation in patients with gram-negative septic shock. © 2002 by the National Kidney Foundation, Inc.

Section snippets

Patients and methods

DHP using an adsorbent column with PMX-F (PMX-F column; Toray Industries Inc, Tokyo, Japan) is recommended for patients with septic shock caused by gram-negative bacilli. However, because blood culture results and blood endotoxin concentrations were not obtained immediately after the onset of shock, the diagnosis of endotoxic shock was based on clinical features (Table 1). Patients with cardiogenic or hemorrhagic shock were excluded from the study. All patients had already been treated with

Results

Table 2 lists causative microorganisms of sepsis in our patients.

. Causative Microorganisms of Sepsis

MicroorganismNo. of Cases
Gram-negative bacillus15
 Escherichia coli8
 Pseudomonas aeruginosa6
 Klebsiella pneumoniae1
Gram-positive bacteria2
 Methicillin-resistant Staphylococcus aureus1
 Enterococcus species1
Unknown/others8
Gram-negative bacilli and gram-positive bacteria were isolated from blood cultures of 15 and 2 patients, respectively. No bacteria could be isolated in 8 patients. Blood endotoxin

Discussion

The administration of endotoxin or pyrogenic LPS extract to healthy humans results in shock with hyperdynamic circulation.9, 10 Furthermore, antiendotoxin therapy using a lipid A analogue blocks the hyperdynamic circulatory disturbance in humans with experimental endotoxemia.27 Cardiodepressant effects of endotoxin have been documented in a number of experimental settings, both in vivo and in cardiomyocytes of endotoxin-treated animals ex vivo in vitro.1, 6, 28, 29, 30, 31 Ventricular

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    Address reprint requests to Kazo Kaizu, MD, Kidney Center, University of Occupational and Environmental Health School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyusyu, 807-8555, Japan. E-mail: [email protected]

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