Potential of therapeutic plasmapheresis in treatment of COVID-19 patients: Immunopathogenesis and coagulopathy

Balagholi, Sahar; Dabbaghi, Rasul; Eshghi, Peyman; Mousavi, Seyed Asadollah; Heshmati, Farhad; Mohammadi, Saeed

doi:10.1016/j.transci.2020.102993

Cited by 42 publications

(53 citation statements)

References 37 publications

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“…This therapeutic potential can be of use as an adjunctive treatment for the management of cytokine storm and coagulopathy in COVID-19 respiratory viral pandemics. 18 Although the relationship between COVID-19 and HUS has not been fully clarified, preliminary results of a study on the effectiveness of C5 inhibitor eculizumab, an important agent that has been used in the treatment of atypical HUS in recent years, in suppressing inflammation in moderate-severe coronavirus-related cases have also been published. 19 , 20 Eculizumab treatment was among the next-line treatments considered after the initiation of plasmapheresis treatment.…”

Section: Discussionmentioning

confidence: 99%

Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19

Dalkıran

Kandur

Kara

et al. 2021

Clin Med Insights Pediatr

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In this case report, we report a pediatric patient with COVID-19 and atypical hemolytic uremic syndrome (aHUS). A 3-year-old girl with fever and respiratory distress was admitted to the hospital. The patient tested positive for COVID-19 by a PCR test. As her respiratory distress increased and blood gas indicated deep respiratory acidosis on the third day of the pediatric intensive care unit follow-up, the patient was intubated and ventilated. Thorax computerized tomography (CT) showed bilateral effusion and atelectasis. During her follow-up, the pleural effusion resolved but there were marked consolidation areas and ground glass opacities compatible with COVID-19 on the follow-up CT. On the 10th day, she became anuric and developed progressive thrombocytopenia and persistent microangiopathic hemolytic anemia, which were suggestive of HUS given a high creatinine level (1.9 mg/dl), an undetectable haptoglobin level, reticulocytosis (8%), and an LDH level of 2540 U/l. Direct Coombs test returned negative. Examination of a peripheral blood smear revealed schistocytes. Disseminated intravascular coagulation was ruled out by normal INR and PTT. In the light of the available findings, we considered the patient to have thrombotic microangiopathy (TMA) triggered by COVID-19. It was not a TTP-form of TMA but rather an aHUS type, based on an ADAMTS13 activity level >5%. Hence, plasmapheresis was performed with fresh frozen plasma (FFP). After 4 weeks, she became completely asymptomatic, and her hemodynamic parameters normalized. COVID-19 induced uncontrolled complement activation leading to the development of aHUS. Early diagnosis and treatment may reduce morbidity and mortality since its treatment options.

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Section: Discussionmentioning

confidence: 99%

Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19

Dalkıran

Kandur

Kara

et al. 2021

Clin Med Insights Pediatr

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“…Plasmapheresis has been reported to have positive outcomes in COVID-19 patients. 24 , 25 The obvious drawback to this would be the lack of resources to undergo plasmapheresis for every hemodynamically unstable COVID-19 patient with signs of coagulopathy.…”

Section: Discussionmentioning

confidence: 99%

Distinct Coagulopathy With Myocardial Injury and Pulmonary Embolism in COVID-19

Fath

Aglan

Varkoly

et al. 2021

Journal of Investigative Medicine High Impact Case Reports

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In this article, we report a case of a 61-year-old male who was diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), presenting with acute respiratory distress syndrome requiring intubation and hemodynamic support, marked D-Dimer and troponin I elevation, worsening ST-elevation myocardial infarction on repeat electrocardiograms, and a negative coronary angiogram ruling out a coronary artery thrombosis or occlusion. With worsening diffuse ST-segment elevation on electrocardiograms and reduced ejection fraction on echocardiography in the setting of systemic inflammation, fulminant myocarditis was highly suspected. Despite optimal medical treatment, the patient’s condition deteriorated and was complicated by cardiac arrest that failed resuscitation. Although myocarditis was initially suspected, the autopsy revealed no evidence of myocarditis or pericarditis but did demonstrate multiple microscopic sites of myocardial ischemia together with thrombi in the left atrium and pulmonary vasculature. Additionally, scattered microscopic cardiomyocyte necrosis with pathological diagnosis of small vessel micro-thrombotic occlusions. These findings are potentially exacerbated by inflammation-induced coagulopathy, hypoxia, hypotension, and stress, that is, a multifactorial etiology. Further research and an improved understanding are needed to define the precise pathophysiology of the coagulopathic state causing widespread micro-thrombosis with subsequent myocardial and pulmonary injury.

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“…Thus, timely initiation of plasmapheresis within this period could determine better health outcomes. It is also necessary to administer TP for the correct duration and quantity to monitor the possible drug removal of speci c therapies and to follow the treatment outcome [27]. The effect of plasmapheresis in sepsis has shown that both the timing and disease severity are important for the bene cial effect of the procedure [28].…”

Section: Discussionmentioning

confidence: 99%

On Whether Therapeutic Plasma Exchange is Effective Against Severe/Critical COVID-19 Pneumonia

Cegolon

Einollahi

Imanizadeh

et al. 2021

Preprint

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Background. There is a risk of novel mutations of SARS-CoV-2 that may render COVID-19 resistant to most of the therapies, including antiviral drugs. The evidence around the application of therapeutic plasma exchange (TPE) for the management of critically ill COVID-19 patients is still provisional and further investigations are needed to confirm its eventual beneficial effects. Methods. We therefore carried out a single-centered retrospective observational non-placebo-controlled trial enrolling 73 inpatients from Baqiyatallah Hospital in Tehran (Iran) with diagnosis of COVID-19 pneumonia confirmed by real-time polymerase chain reaction (RT-PCR) on nasopharyngeal swabs and high-resolution computerized tomography chest scan. These patients were broken down into two groups: Group 1 (30 patients) receiving standard of care (corticosteroids, ceftriaxone, azithromycin, pantoprazole, hydroxychloroquine, lopinavir/ritonavir); and Group 2 (43 patients) receiving the above regimen plus TPE (replacing 2 liter of patients’ plasma by a solution, 50% of normal plasma and 50% of albumin at 5%) administered according to various time schedules. The follow-up time was 30 days and all-cause mortality was the endpoint. Results. Deaths were 6 (14%) in Group 2 and 14 (47%) in Group 1. However, different harmful risk factors prevailed among patients not receiving TPE rather than being equally split between the intervention and control group. We used an algorithm of Structural Equation Modeling (of STATA) to summarize a large pool of potential confounders into a single score (called with the descriptive name “severity”). Disease severity was significantly (Wilkinson rank sum test p-value=0.0000) lower among COVID-19 patients undergoing TPE (median: -2.82; range: -5.18; 7.96) as compared to those non receiving TPE (median: -1.35; range: -3.89; 8.84), confirming that treatment assignment involved a selection bias of patients according to the severity of COVID-19 at hospital admission. The adjustment for confounding was carried out using severity as covariate in Cox regression models. The univariate Hazard Ratio (HR) of 0.68 (95%CI: 0.26; 1.80; p=0.441) for TPE turned to 1.19 (95%CI: 0.43; 3.29; p=0.741) after adjusting for severity. Conclusions. The lower mortality observed among patients receiving TPE was due to a lower severity of COVID-19 rather than TPE effects. TRIAL REGISTRATIONIRCT registration number: IRCT20080901001165N58 (Iranian Registry of Clinical Trials)Registration date: 2020-05-27, 1399/03/07 (retrospectively registered)

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Potential of therapeutic plasmapheresis in treatment of COVID-19 patients: Immunopathogenesis and coagulopathy

Cited by 42 publications

References 37 publications

Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19

Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19

Distinct Coagulopathy With Myocardial Injury and Pulmonary Embolism in COVID-19

On Whether Therapeutic Plasma Exchange is Effective Against Severe/Critical COVID-19 Pneumonia

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