Expert recommendations on blood purification treatment protocol for patients with severe COVID-19

Blood purification in sepsis and COVID-19: what´s new in cytokine and endotoxin hemoadsorption

Sepsis and COVID-19 are two clinical conditions that can lead to a dysregulated inflammatory state causing multiorgan dysfunction, hypercytokinemia, and a high risk of death. Specific subgroups of critically ill patients with particular characteristics could benefit from rescue treatment with hemoadsorption. There is a lack of adequately designed randomized controlled trials evaluating the potential benefits of cytokine or endotoxin hemoadsorption. Critically ill COVID-19 patients with severe acute respiratory failure poorly responsive to conventional treatment could be candidates to receive cytokine hemoadsorption in the presence of high levels of interleukin 6. This treatment can also be suitable for patients with refractory septic shock and hypercytokinemia. In the context of high endotoxin activity, hemoadsorption with polymyxin B could improve clinical parameters and the prognosis of patients with refractory septic shock. Predictive enrichment, using biomarkers or other individual features, identifies potential responders to cytokine, endotoxin, or sequential hemoadsorption. Besides, recognizing the particular subsets of patients likely to respond to one or both types of hemoadsorption will aid the design of future studies that accurately validate the effectiveness of these therapies.

Application of Extracorporeal Apheresis in Treatment of COVID-19: a Rapid Review

Spread of a novel coronavirus infection in 2019 caused by SARS-CoV-2 virus has become a real threat to public health all around the world. The new pandemic required the mobilization of all resources for effective treatment of COVID-19 patients. Extracorporeal apheresis methods were suggested as an addition to the therapy of severe COVID-19 patients, especially when there is a threat of cytokine storm. Cytokine storm has a complex and not fully understood mechanism, and it can result in the multiple organ failure syndrome, associated with high mortality. The main cytokines that play the key role in the cytokine storm are IL-6, IL-10, and TNF-alpha. Removal of the target pro-inflammatory cytokines from the bloodstream can be beneficial in reducing the risk of complications as well as the mortality rate. We describe and compare different methods of extracorporeal apheresis: hemoadsorption, selective plasma filtration, and plasma exchange therapy in the context of their potential use in COVID-19 treatment.

Early Initiation of Extracorporeal Blood Purification Using the AN69ST (oXiris®) Hemofilter as a Treatment Modality for COVID-19 Patients: a Single-Centre Case Series

INTRODUCTION

Severe coronavirus disease 2019 (COVID-19) is characterised by hyperinflammatory state, systemic coagulopathies, and multiorgan involvement, especially acute respiratory distress syndrome (ARDS). We here describe our preliminary clinical experience with COVID-19 patients treated via an early initiation of extracorporeal blood purification combined with systemic heparinisation and respiratory support.

METHODS

Fifteen patients were included; several biomarkers associated with COVID-19 severity were monitored. Personalised treatment was tailored according to the levels of interleukin (IL)-6, IL-8, tumour necrosis factor alpha, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio, thrombocyte counts, D-dimers, and fibrinogen. Treatment consisted of respiratory support, extracorporeal blood purification using the AN69ST (oXiris®) hemofilter, and 300 U/kg heparin to maintain activation clotting time ≥ 180 seconds.

RESULTS

Ten patients presented with severe to critical disease (dyspnoea, hypoxia, respiratory rate > 30/min, peripheral oxygen saturation < 90%, or > 50% lung involvement on X-ray imaging). The median intensive care unit length of stay was 9.3 days (interquartile range 5.3-10.1); two patients developed ARDS and died after 5 and 26 days. Clinical improvement was associated with normalisation (increase) of thrombocytes and white blood cells, stable levels of IL-6 (< 50 ng/mL), and a decrease of CRP and fibrinogen.

CONCLUSION

Continuous monitoring of COVID-19 severity biomarkers and radiological imaging is crucial to assess disease progression, uncontrolled inflammation, and to avert irreversible multiorgan failure. The combination of systemic heparin anticoagulation regimens and extracorporeal blood purification using cytokine-adsorbing hemofilters may reduce hyperinflammation, prevent coagulopathy, and support clinical recovery.

On Therapeutic Plasma Exchange Against Severe COVID-19-Associated Pneumonia: An Observational Clinical Study

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 and vaccines. The evidence around the application of therapeutic plasma exchange (TPE) for the management of critically ill patients with COVID-19 is still provisional, and further investigations are needed to confirm its eventual beneficial effects.

Aims

To assess the effect of TPE on the risk of mortality in patients with COVID-19-associated pneumonia, using three statistical procedures to rule out any threats to validity.

Methods

We therefore carried out a single-centered retrospective observational non-placebo-controlled trial enrolling 73 inpatients from Baqiyatallah Hospital in Tehran (Iran) with the diagnosis of COVID-19-associated pneumonia confirmed by real-time polymerase chain reaction (RT-qPCR) on nasopharyngeal swabs and high-resolution computerized tomography chest scan. These patients were broken down into two groups: Group 1 (30 patients) receiving standard care (corticosteroids, ceftriaxone, azithromycin, pantoprazole, hydroxychloroquine, lopinavir/ritonavir), and Group 2 (43 patients) receiving the above regimen plus TPE (replacing 2 l 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 lower (Wilkinson rank-sum test p &lt; 0.001) among patients with COVID-19 undergoing TPE (median: −2.82; range: −5.18; 7.96) as compared to those not 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 the 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

In this study sample, the lower mortality observed among patients receiving TPE was due to a lower severity of COVID-19 rather than the TPE effects.

Recent Advancements on COVID-19: A Comprehensive Review

Over the last few decades, there have been several global outbreaks of severe respiratory infections. The causes of these outbreaks were coronaviruses that had infected birds, mammals and humans. The outbreaks predominantly caused respiratory tract and gastrointestinal tract symptoms and other mild to very severe clinical signs. The current coronavirus disease-2019 (COVID-19) outbreak, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a rapidly spreading illness affecting millions of people worldwide. Among the countries most affected by the disease are the United States of America (USA), India, Brazil, and Russia, with France recording the highest infection, morbidity, and mortality rates. Since early January 2021, thousands of articles have been published on COVID-19. Most of these articles were consistent with the reports on the mode of transmission, spread, duration, and severity of the sickness. Thus, this review comprehensively discusses the most critical aspects of COVID-19, including etiology, epidemiology, pathogenesis, clinical signs, transmission, pathological changes, diagnosis, treatment, prevention and control, and vaccination.

Plasmapheresis reduces cytokine and immune cell levels in COVID-19 patients with acute respiratory distress syndrome (ARDS)

BACKGROUND

In December 2019, pneumonia associated with a novel coronavirus (COVID-19) was reported in Wuhan, China. Acute respiratory distress syndrome (ARDS) is the most frequently observed complication in COVID-19 patients with high mortality rates.

OBJECTIVE OF STUDY

To observe the clinical effect of plasmapheresis on excessive inflammatory reaction and immune features in patients with severe COVID-19 at risk of ARDS.

MATERIALS AND METHODS

In this single-center study, we included 15 confirmed cases of COVID-19 at Masih Daneshvari Hospital, in March 2020 in Tehran, Iran. COVID-19 cases were confirmed by RT-PCR and CT imaging according to WHO guidelines. Plasmapheresis was performed to alleviate cytokine-induced ARDS. The improvement in oxygen delivery (PaO2/FiO2), total number of T cells, liver enzymes, acute reaction proteins, TNF-α and IL-6 levels were evaluated.

RESULTS

Inflammatory cytokine levels (TNF-α, IL-6), and acute phase reaction proteins including ferritin and CRP were high before plasmapheresis. After plasmapheresis, the levels of PaO2/FiO2, acute phase reactants, inflammatory mediators, liver enzymes and bilirubin were significantly reduced within a week (p < 0.05). In contrast, although the number of T helper cells decreased immediately after plasmapheresis, they rose to above baseline levels after 1 week. Nine out of fifteen patients on non-invasive positive-pressure ventilation (NIPPV) survived whilst the six patients undergoing invasive mechanical ventilation (IMV) died.

CONCLUSION

Our data suggests that plasmapheresis improves systemic cytokine and immune responses in patients with severe COVID-19 who do not undergo IMV. Further controlled studies are required to explore the efficacy of plasmapheresis treatment in patients with COVID-19.

Therapeutic plasma exchange in patients with COVID-19 pneumonia in intensive care unit: Cases series

Introduction

COVID 19 pneumonia can lead to an inappropriate inflammatory response, and can be complicated by acute respiratory distress syndrome, multivisceral failure with a high mortality rate.

Objective

To observe the effect of therapeutic plasma exchange on the excessive inflammatory response.

Materials and methods

In this study, we included 7 confirmed cases of COVID-19 in the intensive care unit (ICU) department of the university hospital of Oujda. COVID-19 cases were confirmed by RT PCR (reverse transcription-polymerase chain) and CT (computerized tomography) imaging according to WHO guidelines. Therapeutic plasma exchange was performed decrease cytokine storm-induced ARDS (Acute respiratory distress syndrome). Inflammation marker assays were performed before and after therapeutic plasma exchange to assess its efficacy.

Results

Levels of inflammatory cytokines (IL-6) and acute phase response proteins, including ferritin and CRP, were elevated before therapeutic plasma exchange.After therapeutic plasma exchange, levels of acute phase reactants, inflammatory mediators, were significantly reduced (p < 0.05).

Conclusion

Our data suggest that therapeutic plasma exchange reduces the inflammatory response in patients with severe COVID-19 not undergoing mechanical ventilation. Further studies are needed to explore the efficacy of therapeutic plasma exchange in patients with COVID-19.

Increasing fetal hemoglobin as a possible key for improvement of hypoxia and saving last breath in COVID-19 patient: “postulating a hypothesis”

Background

COVID-19 patients normally experience mild cold-like symptoms that progress from the early viral response phase through the lung phase to the hyper-inflammation phase. Acute respiratory distress syndrome (ARDS) characterizes the most critical stage of the illness with progressive respiratory failure. Hypoxemia is the most dangerous and challenging problem. We suggest an inductive study approach to postulate a hypothesis and synthesis of supporting evidence as a trial to resolve hypoxia in patients with COVID-19 by increasing the volume of fetal hemoglobin which has a high affinity for oxygen using methods for hypothesis related research evidence synthesis.

Conclusion

We recommend involving umbilical cord fetal blood transfusion or the use of hydroxyl urea as a clinical trial on COVID-19 patients and also for all other types of ARDS to determine its efficacy in correction of hypoxemia, controlling progression of the disease, and increasing survival rate.

Hemadsorption as a Treatment Option for Multisystem Inflammatory Syndrome in Children Associated With COVID-19. A Case Report

Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 is characterized by hypercytokinemia leading to overwhelming inflammation. We describe the use of a hemadsorption device as part of the supportive treatment for cytokine storm.

Kidney involvement in coronavirus-associated diseases (Review)

Since 2003, coronaviruses have caused multiple global pandemic diseases, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and coronavirus disease 2019 (COVID-19). Clinical and autopsy findings suggest that the occurrence of kidney injury during infection may negatively affect the clinical outcomes of infected patients. The authoritative model predicts that outbreaks of other novel coronavirus pneumonias will continue to threaten human health in the future. The aim of the present systematic review was to summarize the basic knowledge of coronavirus, coronavirus infection-associated kidney injury and the corresponding therapies, in order to provide new insights for clinicians to better understand the kidney involvement of coronavirus so that more effective therapeutic strategies can be employed against coronavirus infection in the future.

Analysis of the Clinical and Epidemiological Meaning of Screening Test for SARS-CoV-2: Considerations in the Chronic Kidney Disease Patients during the COVID-19 Pandemic

The COronaVIrus Disease 19 (COVID-19) pandemic is an emerging reality in nephrology. In a continuously changing scenario, we need to assess our patients’ additional risk in terms of attending hemodialysis treatments, follow-up peritoneal dialysis, and kidney transplant visits. The prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-20 infection in the general population plays a pivotal role in estimating the additional COVID-19 risk in chronic kidney disease (CKD) patients. Unfortunately, local prevalence is often obscure, and when we have an estimation, we neglect the number of asymptomatic subjects in the same area and, consequently, the risk of infection in CKD patients. Furthermore, we still have the problem of managing COVID-19 diagnosis and the test’s accuracy. Currently, the gold standard for SARS-CoV-2 detection is a real-time reverse transcription-polymerase chain reaction (rRT-PCR) on respiratory tract samples. rRT-PCR presents some vulnerability related to pre-analytic and analytic problems and could impact strongly on its diagnostic accuracy. Specifically, the operative proceedings to obtain the samples and the different types of diagnostic assay could affect the results of the test. In this scenario, knowing the local prevalence and the local screening test accuracy helps the clinician to perform preventive measures to limit the diffusion of COVID-19 in the CKD population.

Treatment and prognosis of COVID-19: Current scenario and prospects (Review)

SARS-CoV-2 is the seventh member of the family of coronaviruses that can cause infections in humans, termed as COVID-19, which is now a global pandemic. Because it is a novel virus, considerable efforts and extensive studies are needed to fully understand its characteristics. Its symptoms and severity range from mild to critical, depending on several factors, such as host susceptibility to the virus and their immune system, with the most common symptoms being fever, fatigue, sore throat and runny nose. There is no clear treatment available yet, though several options are being explored, with research for vaccines being at the forefront. Traditional Chinese Medicine may also be used as a treatment option. Since this virus is similar to the SARS-CoV and MERS viruses, considerable insight can be gained from previous studies. Although many patients recover completely, there are several factors that lead to poor prognosis. This review summarizes the research carried out so far in terms of treatment options and prognosis factors associated with COVID-19.

Systems Dynamics Modeling of Pandemic Influenza for Strategic Policy Development: a Simulation-Based Analysis of the COVID-19 Case

The novel coronavirus disease 2019 (COVID-19) is a truly wicked problem which has remained a stubborn issue plaguing multiple countries worldwide. The continuously increasing number of infections and deaths has driven several countries to implement control and response strategies including community lockdowns, physical distancing, and travel bans with different levels of success. However, a disease outbreak and the corresponding policies can cause disastrous economic consequences due to business closures and risk minimization behaviors. This paper develops a system dynamics framework of a disease outbreak system covering various policies to evaluate their effectiveness in mitigating transmission and the resulting economic burden. The system dynamics modeling approach captures the relationships, feedbacks, and delays in such a system, revealing meaningful insights on the dynamics of several response strategies.

Controlling Cytokine Storm Is Vital in COVID-19

Corona virus disease 2019 (COVID-19) has caused a global outbreak and severely posed threat to people's health and social stability. Mounting evidence suggests that immunopathological changes, including diminished lymphocytes and elevated cytokines, are important drivers of disease progression and death in coronavirus infections. Cytokine storm not only limits further spread of virus in the body but also induces secondary tissue damage through the secretion of large amounts of active mediators and inflammatory factors. It has been determined that cytokine storm is a major cause of deaths in COVID-19; therefore, in order to reverse the deterioration of severe and critically ill patients from this disease, the cytokine storm has become a key therapeutic target. Although specific mechanisms of the occurrences of cytokine storms in COVID-19 have not been fully illuminated, hyper-activated innate immune responses, and dysregulation of ACE2 (angiotensin converting enzyme 2) expression and its downstream pathways might provide possibilities. Tailored immunoregulatory therapies have been applied to counteract cytokine storms, such as inhibition of cytokines, corticosteroids, blood purification therapy, and mesenchymal stem cell therapy. This review will summarize advances in the research of cytokine storms induced by COVID-19, as well as potential intervention strategies to control cytokine storms.

Prototype Development of an Expert System of Computerized Clinical Guidelines for COVID-19 Diagnosis and Management in Saudi Arabia

The increasing number of COVID-19 patients has increased health care professionals' workloads, making the management of dynamic patient information in a timely and comprehensive manner difficult and sometimes impossible. Compounding this problem is a lack of health care professionals and trained medical staff to handle the increased number of patients. Although Saudi Arabia has recently improved the quality of its health services, there is still no suitable intelligent system that can help health practitioners follow the clinical guidelines and automated risk assessment and treatment plan remotely, which would allow for the effective follow-up of patients of COVID-19. The proposed system includes five sub-systems: an information management system, a knowledge-based expert system, adaptive learning, a notification and follow-up system, and a mobile tracker system. This study shows that, to control epidemics, there is a method to overcome the shortage of specialists in the management of infections in Saudi Arabia, both today and in the future. The availability of computerized clinical guidance and an up-to-date knowledge base play a role in Saudi health organizations, which may not have to constantly train their physician staff and may no longer have to rely on international experts, since the expert system can offer clinicians all the information necessary to treat their patients.

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

Therapeutic plasmapheresis (TP) is the process of the separation and removal of plasma from other blood components and is considered as an adjunctive treatment strategy to the discarded abnormal agent in the management of respiratory viral pandemics. This article reviews the mechanisms of immunopathogenesis and coagulopathy induced by SARS-CoV-2 and the potential benefits of TP as adjunctive treatment in critically COVID-19 patients.

ACE2, TMPRSS2 distribution and extrapulmonary organ injury in patients with COVID-19

At the end of 2019, the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in China. Currently, it is breaking out globally and posing a serious threat to public health. The typically clinical characteristics of COVID-19 patients were fever and respiratory symptoms, and a proportion of patients were accompanied by extrapulmonary symptoms including cardiac injury, kidney injury, liver injury, digestive tract injury, and neurological symptoms. Angiotensin converting enzyme 2 (ACE2) has been proven to be a major receptor for SARS-CoV-2 and could mediate virus entry into cells. And transmembrane protease serine 2 (TMPRSS2) could cleave the spike (S) protein of SARS-CoV-2, which facilitates the fusion of SARS-CoV-2 and cellular membranes. The mRNA expressions of both ACE2 and TMPRSS2 were observed in the heart, digestive tract, liver, kidney, brain and other organs. SARS-CoV-2 may have a capacity to infect extrapulmonary organs due to the expressions of ACE2 and TMPRSS2 in the cells and tissues of these organs. It seems that there is a potential involvement of ACE2 and TMPRSS2 expressions in the virus infection of extrapulmonary organs and the manifestation of symptoms related to these organs in patients with COVID-19. Here, we revealed the expressions of ACE2 and TMPRSS2 in extrapulmonary organs, and we also summarized the clinical manifestation and the management of extrapulmonary complications in patients with COVID-19.

Emerging evidence of a COVID-19 thrombotic syndrome has treatment implications

Reports of widespread thromboses and disseminated intravascular coagulation (DIC) in patients with coronavirus disease 19 (COVID-19) have been rapidly increasing in number. Key features of this disorder include a lack of bleeding risk, only mildly low platelet counts, elevated plasma fibrinogen levels, and detection of both severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and complement components in regions of thrombotic microangiopathy (TMA). This disorder is not typical DIC. Rather, it might be more similar to complement-mediated TMA syndromes, which are well known to rheumatologists who care for patients with severe systemic lupus erythematosus or catastrophic antiphospholipid syndrome. This perspective has critical implications for treatment. Anticoagulation and antiviral agents are standard treatments for DIC but are gravely insufficient for any of the TMA disorders that involve disorders of complement. Mediators of TMA syndromes overlap with those released in cytokine storm, suggesting close connections between ineffective immune responses to SARS-CoV-2, severe pneumonia and life-threatening microangiopathy.

Prospects of plasmapheresis for patients with severe COVID-19

On February 11, 2020, the World Health Organization officially named the infection caused by the new coronavirus "Coronavirus disease 2019" (COVID-19). On February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) officially named the infectious matter "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). Emergence of severe complications with new coronavirus disease is due to the development of hypercytokinaemia, also known as "cytokine storm". These complications comprise acute respiratory distress syndrome (ARDS), respiratory failure and death. Emerging data point to the logic of using extracorporeal haemocorrection to normalise cytokine levels and reduce the severity of organ disorders. The analysis of the literature indicates that to date, a certain positive experience has been accumulated in the world in the application of extracorporeal methods in clinical practice in patients with COVID-19.

Therapeutic plasma exchange in adults with severe COVID-19 infection

OBJECTIVE

To evaluate the therapeutic use of plasma exchange in COVID-19 patients compared to controls.

METHODS

A case series of critically ill adult men and non-pregnant women, ≥18 years of age, with laboratory-confirmed COVID-19, was studied at the Royal Hospital, Oman, from April 17 to May 11, 2020. Therapeutic plasma exchange (TPE) was performed on patients admitted to the intensive care unit (ICU) with confirmed or imminent acute respiratory distress syndrome (ARDS) or severe pneumonia. The analysis was performed using univariate statistics.

RESULTS

A total of 31 COVID-19 patients were included with an overall mean age of 51±15 years (range: 27-76 years); 90% (n=28) were males, and 35% (n=11) of the patients had TPE as a mode of treatment. The TPE group was associated with higher extubation rates than the non-TPE cohort (73% versus 20%; p=0.018). Additionally, patients on TPE had a lower 14 days (0 versus 35%; p=0.033) and 28 days (0 versus 35%; p=0.033) post plasma exchange mortality compared to patients not on TPE. However, all-cause mortality was only marginally lower in the TPE group compared to the non-TPE group (9.1% versus 45%; p=0.055; power=66%). Laboratory and ventilatory parameters also improved post TPE (n = 11).

CONCLUSIONS

The use of TPE in severe COVID-19 patients has been associated with improved outcomes, however, randomized controlled clinical trials are warranted to draw final, conclusive findings.