Technicalities, current evidence, and clinical indications of hemoadsorption in critically ill children

Hemoadsorption devices represent a significant advancement in extracorporeal organ support therapies, enabling the targeted removal of molecules that are not cleared by conventional kidney replacement therapies. Several hemoadsorption devices are currently available, each with distinct characteristics, mechanisms of action, and molecular adsorption profiles that enable their targeted use in a broad range of clinical scenarios in critically ill patients. Their application has recently been explored in pediatric patients with conditions such as septic shock, acute liver failure, hyperinflammatory syndromes, rhabdomyolysis, and intoxications. Preliminary findings suggest both clinical and biochemical improvements, including reduction in severity scores and circulating inflammatory mediators. However, the current body of evidence remains limited, primarily consisting of case reports and small case series, and often lacks robust clinical trial data. In the pediatric population, several challenges persist, including concerns about device sizing, the unintended removal of essential substances, such as medications, nutrients, albumin, and fibrinogen, and the procedural invasiveness, particularly for younger children. Future research should focus on patient stratification to identify those most likely to benefit from hemoadsorption, and on conducting large, multicenter studies to validate its effectiveness and utility in the pediatric setting.