Polymyxin B-immobilized hemoperfusion and mortality in critically ill adult patients with sepsis/septic shock: a systematic review with meta-analysis and trial sequential analysis

Purpose: Polymyxin B-immobilized hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that clears circulating endotoxin. Prior trials have shown that PMX-HP improves surrogate endpoints. We aimed to conduct an evidence synthesis to evaluate the efficacy and safety of PMX-HP in critically ill adult patients with sepsis or septic shock. Methods: We searched for randomized controlled trials (RCTs) in MEDLINE, EMBASE, the Cochrane Library, the Health Technology Assessment Database, CINAHL, Igaku Chuo Zasshi, the National Institute of Health Clinical Trials Register, the World Health Organization International Clinical Trials Registry Platform, the University Hospital Medical Information Network Clinical Trials Registry, the reference lists of retrieved articles, and publications by manufacturers of PMX-HP. The primary outcomes were 28-day all-cause mortality, the number of patients with at least one serious adverse event, and organ dysfunction scores. The GRADE methodology for the certainty of evidence was used. Results: Six trials (857 participants; weighted mean age 62.5 years) proved eligible. Patient-oriented primary outcomes were assessed. The pooled risk ratio (RR) for 28-day mortality associated with PMX-HP was 1.03 [95% confidence interval (CI) 0.78-1.36; I-2 = 25%; n = 797]. The pooled RR for adverse events was 2.17 (95% CI 0.68-6.94; I-2 = 0%; n = 717). Organ dysfunction scores over 24-72 h after PMX-HP treatment did not change significantly (standardized mean difference -0.26; 95% CI -0.64 to 0.12; I-2 = 78%; n = 797). The certainty of the body of evidence was judged as low for both benefit and harm using the GRADE methodology. Conclusions: There is currently insufficient evidence to support the routine use of PMX-HP to treat patients with sepsis or septic shock.