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Intraoperative hemoadsorption and cardiac surgery-associated acute kidney injury: an updated systematic review and
Menghan Liu1, Dan Lin1, Ronghua Zhou2
1Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
Insights
Intraoperative hemoadsorption did not significantly reduce cardiac surgery-associated acute kidney injury (CSA-AKI) in adult patients. Further large-scale trials are needed to confirm potential benefits for severe AKI.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Critical Care Medicine
Background:
- Cardiac surgery-associated acute kidney injury (CSA-AKI) is a significant complication post-cardiopulmonary bypass (CPB).
- Hemoadsorption is explored for its cytokine clearance, but clinical effectiveness in CSA-AKI remains debated.
- Limited management options exist for CSA-AKI, highlighting the need for effective adjunctive therapies.
Purpose of the Study:
- To evaluate the efficacy of intraoperative hemoadsorption versus standard care in preventing CSA-AKI.
- To assess the impact of hemoadsorption on other major clinical outcomes in adult cardiac surgery patients.
- To synthesize evidence from randomized controlled trials (RCTs) on hemoadsorption for CSA-AKI.
Main Methods:
- Systematic review and meta-analysis of 15 RCTs adhering to PRISMA guidelines.
- Searched major databases (PubMed, Medline, Embase, Web of Science, Cochrane Library) up to February 8, 2025.
- Analyzed data using random-effects models, with heterogeneity assessed by I² statistics; Trial Sequential Analysis (TSA) performed.
Main Results:
- Hemoadsorption did not significantly reduce the overall incidence of CSA-AKI (RR 0.80, P=0.08).
- No significant differences observed for CSA-AKI stages 1-3 or need for renal replacement therapy.
- Exploratory analysis showed a reduction in Interleukin-8 (IL-8) levels; mortality and other endpoints were comparable.
Conclusions:
- Intraoperative hemoadsorption did not demonstrate a significant reduction in CSA-AKI or improve clinical outcomes.
- Trends suggested potential benefit in severe AKI, but evidence certainty is very low.
- Insufficient information necessitates large-scale RCTs to definitively establish hemoadsorption's role in CSA-AKI management.
Background:
Cardiac surgery-associated acute kidney injury (CSA-AKI) following cardiopulmonary bypass (CPB) remains a high-risk complication with limited effective management. Hemoadsorption is increasingly used as an adjunctive therapy due to its potent cytokines clearance in experimental settings, yet its clinical efficacy is debated. This study aimed to evaluate the effect of hemoadsorption versus standard care on CSA-AKI and other major outcomes in adult cardiac surgery patients.
Methods:
An updated systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted following PRISMA guidelines. PubMed, Medline, Embase, Web of Science, and the Cochrane Library were systematically searched from inception to 8 February 2025. Eligible RCTs enrolled adult patients undergoing cardiac surgery and compared intraoperative hemoadsorption with standard care, with reported outcomes including CSA-AKI and other major endpoints. Pooled estimates were synthesized using inverse-variance random-effects models, with heterogeneity quantified by I² statistics. Subgroup, sensitivity and trial sequential analyses (TSA) were further performed.
Results:
Fifteen RCTs were included, of which nine reported CSA-AKI (947 patients). Hemoadsorption was not associated with a statistically significant reduction in CSA-AKI (RR 0.80, 95% CI 0.63-1.03, P = 0.08, I2 = 40%, GRADE: very low). The finding was sensitive to model choice and the inclusion of two studies (Diab 2022 and Abou-Arab 2025). Subgroup analyses revealed no significant interaction by device type. TSA indicated that the required information size was not reached. No significant differences were observed for CSA-AKI Stage 1 (RR 0.72, 95% CI 0.49-1.05, P = 0.09, I2 = 16%), Stage 2 (RR 0.66, 95% CI 0.30-1.43, P = 0.29, I2 = 11%), Stage 3 (RR 0.43, 95% CI 0.17-1.05, P = 0.06, I2 = 0%), or renal replacement therapy (RR 0.52, 95% CI 0.22-1.25, P = 0.15, I2 = 0%). Mortality and other clinical endpoints were comparable between groups. Among exploratory outcomes, only an overall reduction in IL-8 was noted (MD -18.23, 95% CI -31.90 to -4.56, P = 0.009, I2 = 40%).
Conclusions:
Intraoperative hemoadsorption did not significantly reduce CSA-AKI or improve clinical outcomes in adult cardiac surgery. Although trends favored severe AKI, very low certainty evidence and insufficient information preclude definitive conclusions, warranting further large-scale RCTs.
Registration:
PROSPERO identifier CRD420250651941.
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