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 CO-VID-19 pneumonia. A randomized clinical trial is ongoing.

Keywords: Blood purification; COVID-19; Case report; Critical illness cytokines; Hemoperfusion.

Fig. 1

Outcome, laboratory data, and respiratory parameters of patients with COVID-19. Data are expressed as means and standard errors. a Number of patients with COVID-19 treated with CytoSorb HP (T) and not treated with CytoSorb HP (C) survivors (S), ns. b Number of patients with COVID-19 treated with CytoSorb HP (T) and not treated with CytoSorb HP (C) I, NI. c CRP serum levels of patients with COVID-19 T and C at hospital admission (admission), and after 6, 12, 18 days. d Lymphocyte's count of patients with COVID-19 treated with CytoSorb HP (T) and not treated with CytoSorb HP (C) at hospital admission (admission), and after 6, 12, 18 days. e PaO₂/FiO₂ ratio of patients with COVID-19 not treated with CytoSorb HP (C) at hospital admission (admission) and after 6, 12 days. PaO₂ was measured in mm Hg and FiO₂ measured as fraction of inspired oxygen. f PaO₂/FiO₂ ratio in COVID-19 patients treated with CytoSorb HP (T) s, ns at hospital admission (admission) and after 6, 12,18 days. PaO₂ was measured in mm Hg and FIO₂ measured as fraction of inspired oxygen. g IL-6 serum levels of survivors (Ts) and not survivor (Tns) treated patients with COVID-19 pre-HP1 and post-HP2. h TNFα serum levels of survivors (Ts) and not survivor (Tns) treated patients with COVID-19 pre-HP 1, and post-HP 2. i IL-8 serum levels of survivors (Ts) and not survivor (Tns) treated patients with COVID-19 pre-HP 1, and post-HP2. j IL-10 serum levels of survivors (Ts) and not survivor (Tns) treated patients with COVID-19 pre-HP 1), and post-HP 2). NI, not incubated; Pre-HP 1, before the first HP session; Post-HP 2, after the second HP session; ns, not survivor; s, survivors; I, intubated; T, treated patient; C, control patient; COVID-19, CoronaVirus Disease 19.