Changes in Cytokines, Haemodynamics and Microcirculation in Patients with Sepsis/Septic Shock Undergoing Continuous Renal Replacement Therapy and Blood Purification with CytoSorb

Abstract

Background: Extracorporeal blood purification therapies have been proposed as a strategy to remove inflammatory mediators during sepsis, thus improving outcome. Objectives: We aimed to evaluate changes in cytokines, haemodynamics and microcirculation during blood purification with Cytosorb adsorber in septic patients. Methods: Prospective observational study on critically ill adult patients with sepsis/septic shock underwent renal replacement therapy (RRT) for acute renal failure and haemoadsorption with Cytosorb as adjunctive therapy for 24 h. Measurements were taken at baseline, after 6 and 24 h: haemodynamic parameters, arterial and central venous blood gases, plasma levels of tumour necrosis factor alpha, interleukin (IL) 1-beta, IL-6, IL-8 and IL-10. The sublingual microcirculation was assessed with sidestream dark field videomicroscopy to evaluate the perfused vessel density (PVD) and microvascular flow quality. Tissue oxygenation and microvascular reactivity were assessed with thenar near infrared spectroscopy (NIRS) with a vascular occlusion test. Results: Nine patients; plasma levels of IL-8 decreased at 24 h (p < 0.05 versus 6 h); no significant variation was found for other cytokines. Haemodynamic remained stable throughout the observation. Microvascular perfusion improved over time, with an increase in PVDs at 6 and 24 h (from 13.9 [13.3–16.4] to 15.7 [15–17.3] and 17 [14.8–18.6] mm/mm2 respectively, p = 0.003) and total vessel densities at 24 h (14.9 [13.9–16.9] vs. 17.9 [15.3–20], p = 0.0015). No significant variation was detected in NIRS-derived parameters. The Sequential Organ Failure Assessment score decreased from 12 ± 3 to 10 ± 1 at 24 h (p = 0.039). Conclusions: In septic patients undergoing RRT, haemoadsorption with Cytosorb seems to determine a decreasing in plasma levels of IL-8, although levels of other cytokines did not vary significantly, and an improvement of microcirculation despite no significant variation in macro-haemodynamics.

Prescription of CRRT: a pathway to optimize therapy

“…More recently, CytoSorb treatment in septic patients undergoing RRT showed a reduction in plasma levels of IL-8 but not of other cytokines. This study (of 24 h duration) showed an improvement of microcirculation despite no significant variation in macro-hemodynamics [87].…”

Clinical characteristics, laboratory outcome characteristics, comorbidities, and complications of related COVID-19 deceased: a systematic review and meta-analysis

“…Moreover, the COVID-19 deceased were also more likely to have a shock. The electrolyte disorder and the decrease of systemic circulation blood volume during the shock would lead to the injury of various organs in the whole body and accelerate the death of the patients [38]. We found that patients with dyspnea were more likely to develop death.…”

The Combined Use of Tocilizumab and Hemoadsorption in a Patient with SARS-COV-2-19-Associated Pneumonia: A Case Report

“…The CytoSorb® can be used as a stand-alone treatment or in combination with a renal replacement treatment or an extracorporeal membrane oxygenation circuit. Some experimental and clinical investigations demonstrated that the use of CytoSorb® is associated both with the reduction of blood levels of many inflammatory cytokines and with the improved survival of patients with septic shock [9, 10]. Notably, tocilizumab is not removed by the CytoSorb® due to its elevated molecular weight [11].…”

“…Our decision was inspired by a case recently described by Bottari et al [10] who successfully treated with the same approach a cytokine release syndrome occurring in a young patient treated with chimeric antigen-receptor modified T-cells and observed the decrease of different markers of inflammation (including IL-6, IL-10, and ferritin) occurring along with the improvement of the gas exchange and of the CRX. In our patient, the decrease of IL-6 and CRP were associated to similar improvements, possibly indicating that the combination of tocilizumab and HA could be valuable for the treatment of SARS-CoV-2-associated interstitial pneumonia or ARDS, likely due to the decrease of the bulk of circulating inflammatory mediators determined by their use.…”