Adjuvant hemoadsorption therapy in patients with severe COVID-19 and related organ failure requiring CRRT or ECMO therapy: A case series

Abstract

Introduction: Severe cases of the COVID-19 are often associated with the development of a fulminant sepsis-like state with a concomitant cytokine release syndrome. Recently, immunomodulating approaches to treat such a hyperinflammation have come into focus, including the use of new extracorporeal organ support therapies such as CytoSorb hemoadsorption designed to remove cytokines and other circulating mediators from blood. Patients and methods: Thirteen critically ill COVID-19 patients with ARDS who received either ECMO therapy and/or CRRT with concomitant multiple organ failure were included. Hemoadsorption therapy was initiated once the patient had established—or was at high risk of developing—a hyperinflammatory state with marked hemodynamic instability or progressive lung failure. Levels of inflammatory markers, vasopressor requirements, oxygenation, and ventilation parameters were measured, as well as clinically relevant outcome measures. Results: Combined therapy was associated with a significant reduction in inflammatory mediators, hemodynamic stabilization with a concomitant decrease in requirements for vasoactive substances, and a pronounced improvement in lung function and the need for ventilatory support. Treatment appeared safe and well-tolerated. Conclusions: In this case series of SARS-CoV-2 infected patients admitted to the intensive care unit with ARDS, we report effective interleukin (IL)-6 removal, reduced norepinephrine requirement, and improved lung function while receiving adjuvant, extracorporeal hemoadsorption therapy in the context of a multimodal treatment approach. The presented protocol for CytoSorb initiation may be a good foundation for the development of further prospective studies in the field and may eventually also be applied to other forms of hyperinflammatory ARDS.

Blood purification therapy in patients with severe COVID-19 requiring veno-venous ECMO therapy: A retrospective study

“…31 These clinical benefits were observed as improvements in oxygenation, but again also as improvements in hemodynamic stabilization with reduction in vasopressor needs. 10,11,28 Both aspects are also in line with our observations and were also described by other authors in patients with a dysregulated inflammatory response for other reasons. 32,33…”

“…31 These clinical benefits were observed as improvements in oxygenation, but again also as improvements in hemodynamic stabilization with reduction in vasopressor needs. 10,11,28 Both aspects are also in line with our observations and were also described by other authors in patients with a dysregulated inflammatory response for other reasons. 32,33 The potential clinical benefit on oxygenation and ventilation invasiveness was described in patients with severe ARDS requiring ECMO support and in pneumogenic sepsis of non-COVID-19 origin.…”

“…Furthermore, several recently published case series and studies support these findings and conclude that CytoSorb therapy was associated with an attenuation of the hyperinflammatory state. 10,11,28 Obviously, not every critically ill COVID-19 patient is hyperinflammatory and the absence of clearly elevated levels of inflammatory mediators might also explain that unselective use of CytoSorb therapy in COVID-19 patients requiring ECMO could not show any clinical benefits in a recent trial. 29 To which extent ECMO therapy by itself is contributing to the development of hyperinflammation is still discussed controversially.…”

Sepsis Management in Southeast Asia: A Review and Clinical Experience

“…Song et al reported the high survival rates of critically-ill COVID-19 patients on extracorporeal membrane oxygenation by using CytoSorb ® therapy in the retrospective multi-centric study [121]. Table 2 summarizes the peer-reviewed articles examining the benefits of CytoSorb ® treatment [115,116,120,[122][123][124][125][126][127][128][129][130][131][132][133][134][135][136][137]. Most of the evidence regarding the effectiveness of CytoSorb ® is based on case series, case studies and retrospective reports.…”

Blood purification could tackle COVID-19?

“…One feature of this device is that it permits combination with other extracorporeal blood treatments, including continuous kidney replacement therapy (CKRT) and extracorporeal membrane oxygenation (ECMO). The co-treatment efficacy of Cytosorb and venous–venous ECMO (V–V ECMO) for severe COVID-19 pneumonia has been investigated in several clinical studies [ 20 – 22 ].…”