An Expert Interpretation on the Evolution of oXiris®-Focused Consensus Statements: From Europe to the Asia-Pacific (2019–2024)

IntroductionThe management of sepsis and hyperinflammatory syndromes through extracorporeal blood purification (EBP) has been a field of intense research and clinical innovation.The oXiris filter, a multifunctional device combining cytokine adsorption, endotoxin removal, renal replacement therapy, and anticoagulant properties, has been at the forefront of this evolution [1].The guidance for clinicians has been shaped by a series of expert consensus documents, each reflecting the cumulative evidence and regional experience of their time.The recently published 2024 Asia-Pacific consensus represents the most recent and comprehensive of these efforts [2].As contributors to both the 2021 and 2024 APAC panels, we provide a unique interpretation of this journey, comparing the three major consensus publications and elucidating the critical advancements and persistent challenges they highlight. The Consensus Trilogy: A Comparative Interpretation 1. The 2019 European Consensus: The FoundationThe inaugural European consensus, published in 2019 [3], was a pioneering effort to create structure around the emerging use of oXiris .Its primary focus was on the septic patient with AKI.Key features included: Scope: Narrowly focused on sepsis and septic shock, emphasizing its use primarily for hemodynamic instability in septic patients with AKI.Evidence Base: Primarily relied on expert opinion, small, single-center studies, case series, and robust in vitro data highlighting the filter's adsorptive capabilities.Key Guidance: It introduced the fundamental concept of using oXiris in patients with a high presumed endotoxin load and/or cytokine storm, often defined by clinical signs of hemodynamic instability.It served as a crucial "how-to" starter guide for the global community.The consensus suggested that treatment should continue until hemodynamic stability is achieved, typically for 48-72 hours.Limitations: Recommendations were largely based on expert opinion and lacked specific, actionable criteria for initiation and discontinuation.It did not formally grade evidence or provide precise biomarker thresholds. The 2021 APAC Consensus: Laying the Regional GroundworkFormulated based on clinical experience gained prior to early 2021 [4], this consensus provided essential guidance tailored to the APAC region's distinct healthcare environments.Scope: Focused specifically on sepsis and septic shock patients with AKI requiring Continuous Renal Replacement Therapy (CRRT).Notably, its development predated the widespread clinical experience with COVID-19, and thus it did not address viral-induced hyperinflammation.Evidence Base: Reflected the initial body of real-world experience from APAC centers.It served as a regional response to the need for practical guidance, building upon the 2019 European consensus while addressing APAC-specific contexts and challenges, such as the limited availability of endotoxin testing.Key Guidance: It reinforced the role of oXiris in septic AKI and offered more concrete practical advice, notably on filter exchange frequency (recommending changes within 12-24 hours, especially in cytokine storm, but allowing extension to 72 hours if the patient was improving).It emphasized initiating treatment based on clinical and laboratory indicators of infection, even without confirmed endotoxin levels.Limitations: Its guidance remained broader, with limited granularity on precise biomarker thresholds for initiation.It also did not extensively address non-septic hyperinflammatory states. The 2024 APAC Consensus: Maturation and RefinementThe 2024 consensus represents a significant evolutionary leap [2], propelled by profound clinical experiences and accelerated evidence generation during the COVID-19 pandemic, which deepened the understanding of cytokine storms.This period witnessed a remarkable surge in