Targeting Cytokine Storm in COVID-19: A Role of Online Hemodiafiltration with Asymmetric Cellulose Triacetate in Maintenance Hemodialysis Patients—A Report of 10 Cases

Abstract

Early reports have suggested that maintenance hemodialysis (MHD) patients could be more susceptible to a severe course of COVID-19. Among the therapeutic approaches, the use of drugs that reduce the cytokine storm characteristic of this disease has been proposed. Some dialyzers, such as the new generation of asymmetric cellulose triacetate (ATA) membranes, could favor the effective elimination of medium-sized molecules and other inflammatory mediators. In this case series, we describe in depth the clinical, analytical, and radiological details, therapeutic aspects, and outcomes of the case series of 10 MHD patients of our dialysis unit, who tested positive for SARS-CoV-2 from 5 October to 30 November 2020. Furthermore, we evaluate the removal of hyperinflammatory parameters with the ATA membrane in postdilution online hemodiafiltration (OL-HDF) in these patients through a variety of biomarkers of systemic inflammation from the diagnosis until stripping. Biochemical blood analysis was carried out at baseline and at days 7 and 14 after diagnosis, respectively. 50% of the patients presented COVID-19 pneumonia and required hospital admission. Median hospitalization time was 21 days. A total of 4 patients developed severe pneumonia (3 of them died) and 1 patient developed moderate pneumonia. Patients who died (n = 3) were more likely to present bilateral pneumonia (100% vs 14.3%) at diagnosis and less reduction in interleukin 6 (IL-6) at day 14, as compared to those who survived. The use of the ATA membrane could be considered a therapeutic option, due to its immunomodulatory effect in MHD patients with SARS-CoV-2 infection, especially at the beginning of the disease, where the inflammatory component is predominant.

Anti-Inflammatory Approach in Chronic Dialysis Patients with SARS-CoV-2: ATA or PMMA Dialyzers?

“…Tarakcioǧlu et al [40] evaluated cytokines removal in 21 stable CHD patients treated with low-flux HD and did not find any difference as to IL-1 beta, IL-6, TNF-alpha, and sIL-2R concentrations between pre-and post-HD specimens. De la Flor et al [41] published a case series of 10 CHD patients affected by SARS-CoV-2 who underwent post-dilution OLHDF with ATA. The authors found a higher IL-6 decrease after 14 days in survivors, although no IL-6 RR was determined and there was not a control group [41].…”

Elevated Levels of Pleiotropic Interleukin-6 (IL-6) and Interleukin-10 (IL-10) are Critically Involved With the Severity and Mortality of COVID-19: An Updated Longitudinal Meta-Analysis and Systematic Review on 147 Studies

“…We conducted this meta-analysis on overall 31 909 COVID-19 patients from 147 studies. 2 , 4 - 7 , 9 - 18 , 24 …”

Can systemic immune inflammation index at admission predict in-hospital mortality in chronic kidney disease patients with SARS-CoV-2 infection?

“… 29 In a report of 10 maintenance HD patients, NLR and LCR were associated with the severe form and mortality of COVID 19. 30 Another study conducting on 62 HD patients showed that higher NLR was associated with the most severe form of COVID-19. 31 In line with the literature, mortality was associated with a lower LCR but higher NLR in our study group.…”