Hemoperfusion with CytoSorb as Adjuvant Therapy in Critically Ill Patients with SARS-CoV2 Pneumonia

Abstract

We report a preliminary experience of adjuvant therapy with Hemoperfusion (HP) in patients with Severe Acute Respiratory Syndrome-CoronaVirus 2 (SARS-CoV2) pneumonia. Currently, there are no approved treatments for CoronaVirus Disease 19 (COVID-19); however, therapeutic strategies based on the preclinical evidence include supportive measures, such as oxygen supplementation, antiviral, and anticoagulant agents. Despite these treatments, 10% of patients worsen and develop severe acute respiratory distress syndrome (ARDS). Since the pathogenic mechanism of ARDS is an uncontrolled inflammatory state, we speculate that removing inflammation effectors from blood may contrast tissue injury and improve clinical outcome. In a scenario of dramatic medical emergency, we conducted an observational study on 9 consecutive patients hospitalized in COVID Intensive Care Unit, where 5 of 9 consecutive patients were treated with HP, due to the emergency overload made it impossible to deliver blood purification in the other 4 patients. COVID-19 was diagnosed through the identification of virus sequences by reverse transcription-PCR on respiratory specimens. All patients had severe pneumonia requiring continuous positive airway pressure. HP was started in all patients 6–7 days after hospital admission. The treated patients (T) received 2 consecutive sessions of HP using CytoSorb cartridge. Our results show a better clinical course of T compared to control patients (C), in fact all T except 1 survived, and only 2 of them were intubated, while all C required intubation and died. Lymphocytopenia worsened in C but not in T. C-reactive protein decreased in both patients, but to a greater extent in T. IL-6, IL-8, and TNF-α decreased after HP, IL-10 did not change. Respiratory function remained stable and did not worsen in T compared to C. The limited sample size and observational study design preclude a sound statement about the potential effectiveness of HP in COVID-19 patients, but our experience suggests a potential therapeutic role of adjuvant CytoSorb HP in the early course of CO­VID-19 pneumonia. A randomized clinical trial is ongoing.

Cytokine Hemoadsorption As Rescue Therapy for Critically Ill Patients with SARS-CoV-2 Pneumonia with Severe Respiratory Failure and Hypercytokinemia

“…Unlike the previous study by Rampino et al 29 , in which the mean PaO2/FiO2 ratio was higher and patients did not require invasive mechanical ventilation, all our patients presented a considerable deleterious clinical situation, with a mean PaO2/FIO2 ratio of 103 (18.4), and 2 of them needed ECMO support. The hemoadsorption delivering strategy in our study was different from Rampino´s study.…”

“…Despite these recommendations, clinical experience is scarce and comes mainly from case reports 26 27 28 and some case series. Rampino et al 29 .reported a case series of 9 consecutive critically ill patients with SARS-CoV-2 and respiratory failure requiring continuous positive airway pressure. There were no patients meeting the clinical criteria for invasive mechanical ventilation at the hemoadsorption initiation.…”

Effects of Different Dialysis Strategies on Inflammatory Cytokine Profile in Maintenance Hemodialysis Patients with COVID-19: A Randomized Trial

“…This is a case of uncontrolled inflammation, which is related to disease severity and unfavorable outcomes [ 4 ]. These findings provided a rational basis for using anti-inflammatory drugs and extracorporeal procedures with a high capacity of cytokine adsorption and removal in the treatment of COVID-19 [ 5 , 6 ]. Clinically, COVID-19 may involve patients of all ages, but it appears particularly severe in old subjects with pre-existent health problems.…”

The Use of CytoSorb Therapy in Critically Ill COVID-19 Patients: Review of the Rationale and Current Clinical Experiences

“…Another observational study from Italy reported on nine consecutive COVID-19 patients with severe pneumonia requiring continuous positive airway pressure [56]. Five of the patients were treated with hemoperfusion using a CytoSorb adsorber, while the remaining four patients were not treated with CytoSorb and served as the control group.…”

“…Based on the available published data, it seems that the most frequent indications for CytoSorb treatment in these critically ill COVID-19 patients were hemodynamic instability, need for renal replacement therapy [26,[31][32][33], and severe ARDS requiring ECMO [55,65]. Apart from one study in which treatment was started at an earlier stage when patients did not need vasopressors or mechanical ventilation [56], most patients were very sick on study entry.…”