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We read with great interest the recent article by Keith et al. who concluded that their retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct therapeutic plasma exchange (TPE) compared to standard care alone [1]. The 28-day mortality rate was 40% in the TPE group (TPE+) versus 65% in the standard care group (TPE−) [1]. We would like to make some comments. The authors reported that the patients who received adjunct TPE had a more favorable fluid balance at 48 h [1]. TPE is not able to induce a negative fluid balance. Patients undergoing adjunct TPE required initiation of renal replacement therapy (RRT) in 67.6% of cases, compared to 51.4% in those receiving standard of care alone [1]. The mortality associated with the new need for RRT was 48% in those receiving TPE compared to 79% in those receiving standard of care alone [1]. Almost 70% of the TPE+ patients required RRT versus only 50% of the patients in the standard of care group [1]. One of the most impressive results seen was the greater relative reduction in mortality among patients receiving TPE who had a primary sepsis diagnosis of pneumonia (pneumonia 11/23 TPE+ [mortality 47.8%] vs 15/17 TPE− [mortality 88.2%]), a situation

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A retrospective study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone: true effect or mediated by a negative fluid balance achieved by RRT?