High volume hemofiltration (HVHF) in sepsis: a comprehensive review of rationale, clinical applicability, potential indications and recommendations for future research.

HVHF can be still seen as a potent powerful immunomodulatory treatment in sepsis. Pleiotropical properties of HVHF give this treatment the possibility to affect not only SIRS but also cardiovascular compounds, clotting and post septic-insult immunoparalysis. By this multimodal approach, HVHF can alter the sepsis network through many targets. The crucial relationship between immunological changes, hemodynamics and survival must be found in future prospective randomised studies. Circulatory cytokines are no longer valuable players except for catecholamine-resistant septic shock. Definitions are of upmost value as ultrafiltrate volume has been correlated in terms of response and survival with the type of disease (sepsis or not) and severity (catecholamine-resistant shock or not). This latter condition can be seen as the best indication for HVHF and probably even more for very high volume hemofiltration (VHVHF). More studies are needed to clarify the role of HVHF in hyperdynamic septic shock (with or without acute renal failure), sepsis and SIRS. They can be seen as potential indications up to now. Possible interferences with activated protein C deserve more attention as both treatments can be given sequentially in the same septic patient or even concomitantly.