[Extracorporeal removal of pathogens using a biomimetic adsorber-A new treatment strategy for the intensive care unit : Seraph® 100 Microbind® Affinity Blood Filter and its fields of application]

BACKGROUND

In 2019 the World Health Organization (WHO) listed antimicrobial resistance among the top 10 threats to global health. The Seraph® 100 Microbind® Affinity blood filter (Seraph® 100) has been in use since 2019 to eliminate pathogens from the bloodstream in addition to anti-infective pharmacotherapy. It is the first device used to rapidly and efficiently reduce the number of circulating bacteria and viruses.

OBJECTIVE

After a background on the concept of extracorporeal pathogen removal in general, this review summarizes the preclinical and clinical data on the Seraph® 100 Affinity Blood Filter. The clinical effect of this treatment and potential therapeutic options are described.

METHODS

Structured PubMed review including references published up to February 2024.

RESULTS

Case reports, uncontrolled observational studies and data from registries show widespread clinical use of the Seraph® 100 ranging from difficult to treat bacterial (super) infections to viral infections. The treatment can be done as stand-alone hemoperfusion or in combination with all forms of kidney replacement therapy as well as in extracorporeal membrane oxygenation.

CONCLUSION

The use of the Seraph® 100 varies in terms of duration, concomitant therapy and clinical settings. Due to the absence of prospective controlled trials the clinical effect cannot be properly evaluated.

Effect of a biomimetic pathogen adsorbing device on inflammatory biomarkers in COVID-19 patients

INTRODUCTION

The Seraph 100 Microbind Affinity blood filter eliminate bacteria, viruses, fungi and toxins from blood stream.

METHODS

This is a prospective multicenter observational biomarker trial in PCR-positive SARS-CoV-2 patients with acute respiratory failure. Biomarkers were sequentially tested at three time points.

RESULTS

Forty-two patients with SARS-CoV-2 detected by PCR with acute respiratory failure were included. When receiving hemoperfusion treatment, 27 (64%) patients were on mechanical ventilation, 41 (98%) patients were treated in the ICU. The 3-month survival was 52%. After one hemoperfusion treatment cycle, D-dimer (p = 0.014), hemoglobin (p = 0.003) and LDH (p = 0.001) concentrations were significantly reduced 4 days after treatment. From the multiplex assay IL-1b, CXCL8/ IL-8, IL-10, IL-13, IL-15, CCL11/Eotaxin, G-CSF, and CXCL10/IP-10 were significantly reduced 1 h after treatment, however not 4 days later.

CONCLUSION

Hemoperfusion with Seraph 100 Microbind Affinity Filter in patients with severe COVID-19 can transiently reduce several inflammatory biomarkers in the blood.

Using the Seraph® 100 Microbind® Affinity blood filter under slow flow conditions through 18 G and 16 G central lines

INTRODUCTION

The Seraph® 100 Microbind® Affinity blood filter (Seraph® 100) has been in use since 2019 for the treatment of fulminant or difficult to treat blood stream infections as an adjunct to pharmacotherapy. In 2020 the device received emergency use authorization by the US Food and Drug Administration for the treatment of critically ill COVID-19 patients with confirmed or imminent respiratory failure. Results of an international registry showed that the Seraph® 100 was operated under blood flow rates of 100-350 mL/min. As those conditions require a large bore central line, a dialysis catheter is currently considered indispensable to operate the Seraph® 100. The use of smaller catheter lumina has neither been evaluated in vitro nor in vivo.

METHODS

In vitro pressure data before and after the Seraph® 100 at various blood pump rates (prepump line 16 G, postpump line 18 G) with saline and human plasma were obtained. Further, anecdotal flow and pressure data of two patients treated with the Seraph® 100 for a COVID-19 infection are reported.

RESULTS

At a pump speed of 50 mL/min pre-Seraph® pressure using saline was -70 [-70 to -60] mm Hg. In comparison, using plasma pre-Seraph® pressure was lower at -120 [-120 to -105] mm Hg; p < 0.001 (t-test). The post-Seraph® pressure at 50 mL/min using saline of 120 [110-130] mm Hg was not different from plasma at 130 [120-140] mm Hg, p = 0.152 (t-test). Blood flow rates of 50 mL/min did not lead to preAP levels below -250 mm Hg in the two clinical cases.

CONCLUSION

Seraph® 100 blood flow rate of 50 mL/min may be achieved using low flow vascular access, allowing to treat a blood volume 72 L in 24 h.

Cardiovascular risk due to diabetes mellitus in patients with chronic kidney disease-prospective data from the German Chronic Kidney Disease cohort

Background

Diabetes mellitus (DM) and chronic kidney disease (CKD) are well-known cardiovascular and mortality risk factors. To what extent they act in an additive manner and whether the etiology of CKD modifies the risk is uncertain.

Methods

The multicenter, prospective, observational German Chronic Kidney Disease study comprises 5217 participants (1868 with DM) with a baseline mean estimated glomerular filtration rate of 30-60 mL/min/1.73 m2 and/or proteinuria >0.5 g/day. We categorized patients whose CKD was caused by cardiovascular or metabolic diseases (CKDcvm) with and without DM, as opposed to genuine CKD (CKDgen) with and without DM. Recorded outcomes were first events of non-cardiovascular and cardiovascular death, 4-point major adverse cardiovascular events (4-point MACE) and hospitalization for heart failure (HHF).

Results

During the 6.5-year follow-up 603 (12%) non-cardiovascular and 209 (4%) cardiovascular deaths, 645 (12%) 4-point MACE, and 398 (8%) HHF were observed, most frequently in patients with DM having CKDcvm. DM increased the risk of non-cardiovascular [hazard ratio (HR) 1.92; 95% confidence interval (CI) 1.59-2.32] and cardiovascular (HR 2.25; 95% CI 1.62-3.12) deaths, 4-point MACE (HR 1.93; 95% CI 1.62-2.31) and HHF (HR 1.87; 95% CI 1.48-2.36). Mortality risks were elevated by DM to a similar extent in CKDcvm and CKDgen, but for HHF in CKDcvm only (HR 2.07; 95% CI 1.55-2.77). In patients with DM, CKDcvm (versus CKDgen) only increased the risk for HHF (HR 1.93; 95% CI 1.15-3.22).

Conclusions

DM contributes to cardiovascular and mortality excess risk in patients with moderate to severe CKD in both, CKDcvm and CKDgen. Patients with DM and CKDcvm are particularly susceptible to HHF.

Research priorities for therapeutic plasma exchange in critically ill patients

Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.

[Hemoperfusion and plasmapheresis in the intensive care unit]

In addition to kidney replacement procedures, several other extracorporeal procedures are employed in the intensive care unit. Hemoperfusion with activated charcoal was the predominant treatment used for removal of toxins from the 1970s until the millennium. Nowadays, this treatment does no longer play a clinically meaningful role as even strongly protein-bound toxins can be removed by effective dialysis procedures in case poisoning. The concept of a cytokine adsorber was introduced 10 years ago, which is directed towards withstanding the cytokine storm. Despite negative data from prospective randomized controlled studies, its use is steadily increasing in Germany. A totally different treatment concept is the biomimetic pathogen adsorber, which removes bacteria, viruses and fungi from the bloodstream by binding to immobilized heparin. Whether this rapid reduction of the pathogen load translates into an improvement of clinically relevant endpoints is unclear, as prospective randomized controlled studies are lacking. For the early hours of septic shock a very old procedure, plasmapheresis, has recently regained interest. The results of two large randomized controlled studies in this setting from Europe and Canada will become available in 2025/2026. The rationale to use plasma exchange in early sepsis is that this procedure not only removes cytokines but also replenishes reduced levels of protective factors, such as angiopoietin‑1, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) and protein C, if fresh plasma is used as exchange fluid. All afore mentioned procedures do not only have a different mode of action but are also used at seperate time points of bloodstream infections and/or sepsis.

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.

SARS-CoV-2 infection in chronic kidney disease patients with pre-existing dialysis: description across different pandemic intervals and effect on disease course (mortality)

PURPOSE

Patients suffering from chronic kidney disease (CKD) are in general at high risk for severe coronavirus disease (COVID-19) but dialysis-dependency (CKD5D) is poorly understood. We aimed to describe CKD5D patients in the different intervals of the pandemic and to evaluate pre-existing dialysis dependency as a potential risk factor for mortality.

METHODS

In this multicentre cohort study, data from German study sites of the Lean European Open Survey on SARS-CoV-2-infected patients (LEOSS) were used. We multiply imputed missing data, performed subsequent analyses in each of the imputed data sets and pooled the results. Cases (CKD5D) and controls (CKD not requiring dialysis) were matched 1:1 by propensity-scoring. Effects on fatal outcome were calculated by multivariable logistic regression.

RESULTS

The cohort consisted of 207 patients suffering from CKD5D and 964 potential controls. Multivariable regression of the whole cohort identified age (> 85 years adjusted odds ratio (aOR) 7.34, 95% CI 2.45-21.99), chronic heart failure (aOR 1.67, 95% CI 1.25-2.23), coronary artery disease (aOR 1.41, 95% CI 1.05-1.89) and active oncological disease (aOR 1.73, 95% CI 1.07-2.80) as risk factors for fatal outcome. Dialysis-dependency was not associated with a fatal outcome-neither in this analysis (aOR 1.08, 95% CI 0.75-1.54) nor in the conditional multivariable regression after matching (aOR 1.34, 95% CI 0.70-2.59).

CONCLUSIONS

In the present multicentre German cohort, dialysis dependency is not linked to fatal outcome in SARS-CoV-2-infected CKD patients. However, the mortality rate of 26% demonstrates that CKD patients are an extreme vulnerable population, irrespective of pre-existing dialysis-dependency.

Single-Dose Pharmacokinetics and Total Removal of Cyclophosphamide in a Patient with Acute Kidney Injury Undergoing Intermittent Haemodialysis and Prolonged Intermittent Kidney Replacement Therapy: A Case Report

The largest study on cyclophosphamide pharmacokinetics in dialysis patients comprises of 6 subjects. In the 2 decades since these data were obtained, dialyser membranes, treatment intensities, and treatment duration have changed considerably making new pharmacokinetic studies desirable. We aimed to readdress the pharmacokinetics of cyclophosphamide in a 74-year-old critically ill male suffering from ANCA-associated vasculitis. Due to an acute-on-chronic kidney injury, he underwent intermittent (IHD) and prolonged intermittent kidney replacement therapy (PIKRT). IHD was started 7 h after end of a cyclophosphamide infusion with a blood/dialysate flow of 300 mL/min for 255 min, followed by PIKRT with a blood/dialysate flow of 140 mL/min for 540 min, both using a 1.3 m2 polysulphone high-flux dialyser (F60S, Fresenius Medical Care). Peak concentration of cyclophosphamide was 20.2 mg/L. Using IHD and PIKRT serum concentration of cyclophosphamide decreased to 1.2 mg/L after IHD and to <0.1 mg/L after PIKRT with dialyser-clearances of 153.0 mL/min and 84.9 mL/min, respectively. Total recovery of cyclophosphamide, calculated from the collected dialysate, was 57.5 mg (7.7% of administered dose) for IHD and was 8.3 mg (1.1% of administered dose) for PIKRT. By using IHD with a high-flux dialyser cyclophosphamide could be eliminated. Remaining cyclophosphamide should be eliminated by PIKRT. Hence, even in the absence of renal function a dose >50% of the recommended for patient with normal renal function may be applied, as complete elimination of the parent drug by modern dialysis is feasible.

Staphylococcus aureus binding to Seraph® 100 Microbind® Affinity Filter: Effects of surface protein expression and treatment duration

INTRODUCTION

Extracorporeal blood purification systems represent a promising alternative for treatment of blood stream infections with multiresistant bacteria.

OBJECTIVES

The aim of this study was to analyse the binding activity of S. aureus to Seraph affinity filters based on heparin coated beads and to identify effectors influencing this binding activity.

RESULTS

To test the binding activity, we used gfp-expressing S. aureus Newman strains inoculated either in 0.9% NaCl or in blood plasma and determined the number of unbound bacteria by FACS analyses after passing through Seraph affinity filters. The binding activity of S. aureus was clearly impaired in human plasma: while a percent removal of 42% was observed in 0.9% NaCl (p-value 0.0472) using Seraph mini columns, a percent removal of only 10% was achieved in human plasma (p-value 0.0934). The different composition of surface proteins in S. aureus caused by the loss of SarA, SigB, Lgt, and SaeS had no significant influence on its binding activity. In a clinically relevant approach using the Seraph® 100 Microbind® Affinity Filter and 1000 ml of human blood plasma from four different donors, the duration of treatment was shown to have a critical effect on the rate of bacterial reduction. Within the first four hours, the number of bacteria decreased continuously and the reduction in bacteria reached statistical significance after two hours of treatment (percentage reduction 64%, p-value 0.01165). The final reduction after four hours of treatment was close to 90% and is dependent on donor. The capacity of Seraph® 100 for S. aureus in human plasma was approximately 5 x 108 cells.

CONCLUSIONS

The Seraph affinity filter, based on heparin-coated beads, is a highly efficient method for reducing S. aureus in human blood plasma, with efficiency dependent on blood plasma composition and treatment duration.

Safety and efficacy of the Seraph® 100 Microbind® Affinity Blood Filter to remove bacteria from the blood stream: results of the first in human study

Background

Bacterial burden as well as duration of bacteremia influence the outcome of patients with bloodstream infections. Promptly decreasing bacterial load in the blood by using extracorporeal devices in addition to anti-infective therapy has recently been explored. Preclinical studies with the Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100), which consists of heparin that is covalently bound to polymer beads, have demonstrated an effective binding of bacteria and viruses. Pathogens adhere to the heparin coated polymer beads in the adsorber as they would normally do to heparan sulfate on cell surfaces. Using this biomimetic principle, the Seraph® 100 could help to decrease bacterial burden in vivo.

Methods

This first in human, prospective, multicenter, non-randomized interventional study included patients with blood culture positive bloodstream infection and the need for kidney replacement therapy as an adjunctive treatment for bloodstream infections. We performed a single four-hour hemoperfusion treatment with the Seraph® 100 in conjunction with a dialysis procedure. Post procedure follow up was 14 days.

Results

Fifteen hemodialysis patients (3F/12 M, age 74.0 [68.0–78.5] years, dialysis vintage 28.0 [11.0–45.0] months) were enrolled. Seraph® 100 treatment started 66.4 [45.7–80.6] hours after the initial positive blood culture was drawn. During the treatment with the Seraph® 100 with a median blood flow of 285 [225–300] ml/min no device or treatment related adverse events were reported. Blood pressure and heart rate remained stable while peripheral oxygen saturation improved during the treatment from 98.0 [92.5–98.0] to 99.0 [98.0–99.5] %; p = 0.0184. Four patients still had positive blood culture at the start of Seraph® 100 treatment. In one patient blood cultures turned negative during treatment. The time to positivity (TTP) was increased between inflow and outflow blood cultures by 36 [− 7.2 to 96.3] minutes. However, overall TTP increase was not statistical significant.

Conclusions

Seraph® 100 treatment was well tolerated. Adding Seraph® 100 to antibiotics early in the course of bacteremia might result in a faster resolution of bloodstream infections, which has to be evaluated in further studies.

Trail registration: ClinicalTrials.gov Identifier: NCT02914132, first posted September 26, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04044-7.

High Macrophage Densities in Native Kidney Biopsies Correlate With Renal Dysfunction and Promote ESRD

Introduction

Macrophages and monocytes are main players in innate immunity. The relevance of mononuclear phagocyte infiltrates on clinical outcomes remains to be determined in native kidney diseases.

Methods

Our cross-sectional study included 324 patients with diagnostic renal biopsies comprising 17 disease entities and normal renal tissues for comparison. All samples were stained for CD68⁺ macrophages. Selected groups were further subtyped for CD14⁺ monocytes and CD163⁺ alternatively activated macrophages. Using precise pixel-based digital measurements, we quantified cell densities as positively stained areas in renal cortex and medulla as well as whole renal tissue. Laboratory and clinical data of all cases at the time of biopsy and additional follow-up data in 158 cases were accessible.

Results

Biopsies with renal disease consistently revealed higher CD68⁺-macrophage densities and CD163⁺-macrophage densities in cortex and medulla compared to controls. High macrophage densities correlated with impaired renal function at biopsy and at follow-up in all diseases and in diseases analyzed separately. High cortical CD68⁺-macrophage densities preceded shorter renal survival, defined as requirement of permanent dialysis. CD14⁺ monocyte densities showed no difference compared to controls and did not correlate with renal function.

Conclusion

Precise quantification of macrophage densities in renal biopsies may contribute to risk stratification to identify patients with high risk for end-stage renal disease (ESRD) and might be a promising therapeutic target in renal disease.

More Drug Monitoring and Less CT Scans of the Brain: Gabapentin Overdose in Two Peritoneal Dialysis Patients

In parallel with the decline of renal excretory function, drug dosing of many drugs becomes more challenging. Finding the right dose is even more difficult if kidney replacement therapy is instituted. This is further aggravated by the fact that even for substances with a narrow therapeutic range, drug monitoring is only rarely offered, let alone advocated. This holds also true for gabapentin, an anticonvulsant drug that is increasingly prescribed for indications such as cancer-related pain, restless legs syndrome, migraine, or uremic pruritus. The drug is excreted unchanged in urine, so plasma clearance of gabapentin is directly proportional to creatinine clearance. Hence, renal impairment reduces gabapentin excretion and increases plasma gabapentin concentrations in a linear fashion. Therefore, the elimination half-life of gabapentin is between 5 and 9 h, in patients with normal renal function but increases to 132 h in patients on dialysis. Epidemiological data from the USRDS underline this problem. About 19% of the 140,899 adult USA patients enrolled in Medicare coverage received gabapentin in 2011. Its use was associated with an increased risk of altered mental status, fall, and fracture. We report 2 patients in which overdose of gabapentin occurred. In 1 patient, severe neurological symptoms prompted an extensive diagnostic work up, while the underlying cause of the clinical presentation was a supra-therapeutic drug level of gabapentin. Consequently, symptoms subsided with the discontinuation of the drug. Indication and drug dose of gabapentin in dialysis patients should be tightly controlled, and drug monitoring used to avoid unintended overdose.

Targeting the innate repair receptor axis via erythropoietin or pyroglutamate helix B surface peptide attenuates hemolytic-uremic syndrome in mice

Hemolytic-uremic syndrome (HUS) can occur as a systemic complication of infections with Shiga toxin (Stx)-producing Escherichia coli and is characterized by microangiopathic hemolytic anemia and acute kidney injury. Hitherto, therapy has been limited to organ-supportive strategies. Erythropoietin (EPO) stimulates erythropoiesis and is approved for the treatment of certain forms of anemia, but not for HUS-associated hemolytic anemia. EPO and its non-hematopoietic analog pyroglutamate helix B surface peptide (pHBSP) have been shown to mediate tissue protection via an innate repair receptor (IRR) that is pharmacologically distinct from the erythropoiesis-mediating receptor (EPO-R). Here, we investigated the changes in endogenous EPO levels in patients with HUS and in piglets and mice subjected to preclinical HUS models. We found that endogenous EPO was elevated in plasma of humans, piglets, and mice with HUS, regardless of species and degree of anemia, suggesting that EPO signaling plays a role in HUS pathology. Therefore, we aimed to examine the therapeutic potential of EPO and pHBSP in mice with Stx-induced HUS. Administration of EPO or pHBSP improved 7-day survival and attenuated renal oxidative stress but did not significantly reduce renal dysfunction and injury in the employed model. pHBSP, but not EPO, attenuated renal nitrosative stress and reduced tubular dedifferentiation. In conclusion, targeting the EPO-R/IRR axis reduced mortality and renal oxidative stress in murine HUS without occurrence of thromboembolic complications or other adverse side effects. We therefore suggest that repurposing EPO for the treatment of patients with hemolytic anemia in HUS should be systematically investigated in future clinical trials.

MO693: Longitudinal Intraindividual Changes of Peritoneal Histology over Time in 37 Peritoneal Dialysis Patients

BACKGROUND AND AIMS

The long-term use of peritoneal dialysis is limited due to changes of the peritoneum. Those can be attributed to both, uremia and the effect of the peritoneal dialysis solution on the peritoneum. Although the effect of peritoneal dialysis on the peritoneal histology has been investigated for more than 40 years, most studies fail to report intraindividual changes of the peritoneum but report cross-sectional data from different patients at different timepoints of their dialysis career. The aim of our study was to investigate the intraindividual changes over time associated with peritoneal dialysis as part of the GRiP (German Registry in PD).

METHOD

Among patients documented by the GRiP study group 37 patients were identified in which two peritoneal samples were collected at least 2 months apart. The median [IQR] patient age was 63.6 [52.8–70.5] years with a median [IQR] BMI of 27.8 [22.4–31.8] kg/m2. The time between the two biopsies was 20.0 [7.2–27.6] months. Removal or change of the PD catheter was due to infection in 20 of the 37 patients (54%). Samples from the parietal peritoneum were collected at prespecified locations. Routine histology using hematoxylin–eosin was performed. The thickness of the submesothelial compacta was analysed with AxioVision SE64 Rel.4.9. software. GraphPad Prism 9 (San Diego, CA, USA) was used for statistical analysis. Comparison between histological parameters at implantation and explantation was done by using a paired t-test using a significance level of P &lt; 0.05.

RESULTS

Comparing the intraindividual thickness of the compacta at the time of implantation and explantation of the peritoneal dialysis catheter we saw a significant increase of the median [IQR] ‘minimum thickness’ from 50.0 [20.5–89.5] µm to 130.0 [42.5–195.5] µm, the ‘average thickness’ from 102.0 [77.75–162.5.5] µm to 181.5 [123.3–265.5] as well as the ‘maximum thickness’ from 148.0 [107.0–208.0] µm to 240 [182.0–381.0] (Fig. 1). Further, the degree of peritoneal fibrosis increased significantly (Fig. 2).

CONCLUSION

The longitudinal, intraindividual assessment of peritoneal biopsies in a sizeable cohort of patients confirms previous cross-sectional data showing an increase in the thickness of the sumesothelial compacta over time.

MO362: Braunschweig Body Composition, Butterfly Sonography and Drug Dosing in AKI Study (B3 D2 AKI––Study)

BACKGROUND AND AIMS

In-hospital AKI is associated with increased morbidity and mortality. AKI Alert systems are frequently used to allow time detection of AKI patients based on changes in creatinine. We aimed to examine the hydration status, medication errors and prior existing CKD in a series of AKI 3 patients in a tertiary care hospital.

METHOD

Prospective single centre cohort study. Study was approved by the local IRB. Hydration status was assessed by Bioimpedance using the body composition monitor (Fresenius Medical Care). Renal size and exclusion of postrenal failure were accomplished using a point of care ultrasound system (Butterfly Network Inc.). Pharmacotherapy was entered into the Federal Medication Plan of Germany (Bundesmedikationsplan).

RESULTS

A total of 101 patients with AKI 3 were identified based on changes in creatinine only. The median (IQR) age was 74.0 (64.7–82.0) years with a BMI of 27.8 (23.5–34.2) kg/m2. The baseline creatinine of the patients was 1.53 (0.92–2.85) mg/dL. At the time of AKI 3 diagnosis the median [IQR] 4.1 (1.9–5.9) L. Systolic blood pressure was 116 (100–140) mmHg (Fig. 1). Median (IQR) kidney length was 10.4 (9.2–11.7) cm.

Polypharmacy (&gt; 5 drugs) was seen in 89.7% of all patients. Almost half of the patients (48.3%) received 10 or more drugs. A total of 38% of patients receiving an antibiotic received an inadequately high dose, followed by 7.8% receiving an inadequate dosing of oral antidiabetic drugs.

CONCLUSION

Patients detected by an AKI alert in a tertiary care hospital did mostly neither exhibit low blood pressure nor volume depletion. Postrenal AKI was undetected in 1 out of 101 patients. Medication dosing errors were frequently seen, especially in the dosing of antibiotics. A joined nephron-pharmacological approach seems to be important in patients with hospital acquired AKI 3.

MO343: Deep Analysis of The AKI—CKD in Allogeneic Stem Cell Transplantation—A Big Data Approach

BACKGROUND AND AIMS

Acute kidney injury (AKI) is a common complication in allogeneic stem cell transplantation (SCT). Although short-lived, i.e. &lt; 90 days, in the majority of patients renal injury can persist for more than 3 months fulfilling the criteria of chronic kidney disease (CKD). So far, only a few publications have shown robust data based on larger patient populations. The aim of this project is to analyse the incidence and severity of AKI in the context of an allogeneic SCT and the transition into CKD.

METHOD

Over a 17-year period, 1394 allogeneic stem cell transplants were performed at our tertiary center. Of those, 42 were second transplants. For 1387, a detailed history of creatinine (n = 142 563) and eGFR (n = 96 689) could be extracted from the Enterprise Clinical Research Data Warehouse. The classification of the respective AKI stages was based on the current KDIGO classification relying solely on the changes in serum creatinine. For AKI, an increase in serum creatinine of ≥ 0.3 mg/dL (26.5 µmol/L) within 48 h or an increase in serum creatinine to ≥ 1.5× baseline within 7 days was used. Persistence of impaired renal function beyond day 90 was defined as CKD. For the analysis of big data and classification of the AKI/CKD an algorithm was programmed. Validation of the results was performed using a colour-coded visualization of renal function (Fig. 1).

RESULTS

Between 1 January 2003 and 31 December 2020, 239 252 values for creatinine and eGFR were enriched for 1387 transplantations for a period between day –28 before today + 118 after allogeneic stem cell transplantation. The overall incidence of AKI was 86% (n = 1199). A total of 993 patients (83%) have shown an AKIN 1, 173 (14%) an AKIN 2 and 33 (3%) an AKIN 3. Of those, 122 (13%) patients died before day + 90 after allogeneic stem cell transplantation and were therefore excluded from CKD analysis. For 271 of 833 patients (33%), the transition to chronic kidney disease has been observed. Further information on patient characteristics, underlying disease, transplant coordinates and related complications and relapse mortality are shown in Table 1.

CONCLUSION

AKI after SCT is the rule and not the exception. As the vast majority of patients show AKIN 1, it might be often clinically overlooked. However, early intervention might mitigate the development of long-term renal impairment. Automated detection (AKI alert systems) as well as identification and subsequent avoidance of factors contributing or aggravating injury (e.g. conditioning, immunosuppression, perfusion, tissue edema, inappropriate dosing of drugs) might minimize long-term renal complications in allogeneic SCT.

Interim analysis of the COSA (COVID-19 patients treated with the Seraph® 100 Microbind® Affinity filter) registry

BACKGROUND

The Seraph® 100 Microbind® Affinity Blood Filter is a haemoperfusion device that is licensed for the reduction of pathogens, including several viruses, in the blood. It received Emergency Use Authorization for the treatment of severe coronavirus disease 2019 (COVID-19) by the Food and Drug Administration (FDA). Several studies have shown that the blood viral load of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) correlates with adverse outcomes and removal of the nucleocapsid of the SARS-CoV-2 virus by the Seraph® 100 has been recently demonstrated. The aim of this registry was to evaluate the safety and efficacy of Seraph® 100 treatment for COVID-19 patients.

METHODS

Twelve hospitals from six countries representing two continents documented patient and treatment characteristics as well as outcome parameters without reimbursement. Additionally, mortality and safety results of the device were reported. A total of 102 treatment sessions in 82 patients were documented in the registry. Four patients were excluded from mortality analysis due to incomplete outcome data, which were available in the other 78 patients.

RESULTS

Overall, a 30-day mortality rate of 46.2% in the 78 patients with complete follow-up was reported. The median treatment time was 5.00 h (4.00-13.42) and 43.1% of the treatments were performed as haemoperfusion only. Adverse events of the Seraph® 100 treatment were reported in 8.8% of the 102 treatments and represented the premature end of treatment due to circuit failure. Patients who died were treated later in their intensive care unit (ICU) stay and onset of COVID symptoms. They also had higher ferritin levels. Multivariate Cox regression revealed that delayed Seraph® 100 treatment after ICU admission (>60 h), as well as bacterial superinfection, were associated with mortality. While average predicted mortality rate according to Sequential Organ Failure Assessment (SOFA) score in ICU patients was 56.7%, the observed mortality was 50.7%. In non-ICU patients, Coronavirus Clinical Characterisation Consortium (4C) score average predicted a mortality rate of 38.0%, while the observed mortality rate was 11.1%.

CONCLUSIONS

The treatment of COVID-19 patients with Seraph® 100 is well tolerated and the circuit failure rate was lower than previously reported for kidney replacement therapy (KRT) in COVID-19 patients. Mortality correlated with late initiation of Seraph treatment after ICU admission and bacterial superinfection. Compared with predicted mortality according to 4C and SOFA scores, mortality of Seraph® 100-treated patients reported in the registry was lower.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Melkersson-Rosenthal syndrome in the context of sarcoidosis: a case report

Background

Melkersson–Rosenthal syndrome is a rare disease characterized by the triad of recurrent orofacial swelling with facial paralysis and fissured dorsal tongue. Histologically, noncaseating granulomatous inflammation occurs that confirms the diagnosis. Overlaps between granulomatous diseases such as sarcoidosis and Crohn’s disease are described. Systemic corticosteroid therapy is the treatment of choice for acute attacks.

Case presentation

We here present a case of a 59-year-old White woman suffering from Melkersson–Rosenthal syndrome with a past history of sarcoidosis on therapy with leflunomide in combination with low-dose tacrolimus successfully treated with the anti-leprosy drug clofazimine after failure of systemic steroid therapy.

Conclusions

We propose clofazimine as an alternative treatment in steroid-refractory cases.