The last dance of coupled plasma filtration adsorption (CPFA): Clinical outcomes, challenges, and perspectives in multiple organ support therapy

Background: Coupled plasma filtration and adsorption (CPFA) is a non-selective extracorporeal technique designed to modulate systemic inflammation through plasma filtration combined with resin-based adsorption. While preclinical data were promising, randomized trials in septic shock yielded conflicting results and raised safety concerns, leading to its discontinuation. Nonetheless, selected patients might benefit from CPFA when adequately delivered. Methods: We performed a retrospective, single-center observational study of 36 critically ill patients treated with CPFA between 2019 and 2022. A total of 56 CPFA sessions were analyzed, evaluating clinical indications, plasma-treated volume (VPT), hemodynamic changes, and clinical outcomes. Results: The main indication was sepsis (75%), followed by rhabdomyolysis and intoxications (8% each). Most patients received one to two sessions, with a mean duration of 9 ± 1 h and a VPT of 10,103 ± 4275 mL. Survival at 72 h and 28 days was 85% and 61%, respectively, with no early deaths. Patients achieving a VPT ⩾18% of estimated plasma volume had better 28-day survival (81% vs 42%, p = 0.03), although they had lower initial severity scores. A non-significant trend toward vasopressor reduction was observed. No major adverse events occurred. Conclusion: In this cohort, CPFA was feasible and safe, with possible hemodynamic and survival benefits when a sufficient plasma-treated volume was reached. Patient selection and optimized treatment delivery appear crucial. However, the retrospective design and lack of a control group limit definitive conclusions. Future research should focus on more effective and targeted extracorporeal strategies for immune modulation in critically ill patients.