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Iyer SPN, Pino CJ, Yessayan LT, Goldstein SL, Weir MR, Westover AJ, Catanzaro DA, Chung KK, Humes HD. Increasing Eligibility to Transplant Through the Selective Cytopheretic Device: A Review of Case Reports Across Multiple Clinical Conditions. Transplant Direct 2024; 10:e1627. [PMID: 38769980 PMCID: PMC11104718 DOI: 10.1097/txd.0000000000001627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 05/22/2024] Open
Abstract
A stable, minimum physiological health status is required for patients to qualify for transplant or artificial organ support eligibility to ensure the recipient has enough reserve to survive the perioperative transplant period. Herein, we present a novel strategy to stabilize and improve patient clinical status through extracorporeal immunomodulation of systemic hyperinflammation with impact on multiple organ systems to increase eligibility and feasibility for transplant/device implantation. This involves treatment with the selective cytopheretic device (SCD), a cell-directed extracorporeal therapy shown to adhere and immunomodulate activated neutrophils and monocytes toward resolution of systemic inflammation. In this overview, we describe a case series of successful transition of pediatric and adult patients with multiorgan failure to successful transplant/device implantation procedures by treatment with the SCD in the following clinical situations: pediatric hemophagocytic lymphohistiocytosis, and adult hepatorenal and cardiorenal syndromes. Application of the SCD in these cases may represent a novel paradigm in increasing clinical eligibility of patients to successful transplant outcomes.
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Affiliation(s)
| | - Christopher J. Pino
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Lenar T. Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Stuart L. Goldstein
- Division of Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Angela J. Westover
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | - Kevin K. Chung
- Department of Medical Affairs, SeaStar Medical, Denver, CO
| | - H. David Humes
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
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Goldstein SL, Ollberding NJ, Askenazi DJ, Basu RK, Selewski DT, Krallman KA, Yessayan L, Humes HD. Selective Cytopheretic Device Use in Continuous Kidney Replacement Therapy in Children: A Cohort Study With a Historical Comparator. Kidney Med 2024; 6:100792. [PMID: 38576525 PMCID: PMC10990749 DOI: 10.1016/j.xkme.2024.100792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Rationale and Objective Critically ill children with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) are at increased risk of death. The selective cytopheretic device (SCD) promotes an immunomodulatory effect at circuit-ionized calcium of <0.40 mmol/L. In an adult CRRT patient study, SCD-treated patients reported improved survival or dialysis independence. We reported safety data from children who received CRRT-SCD therapy and compared outcomes with a historic pediatric CRRT cohort. Study Design We performed 2 prospective multicenter studies to evaluate the safety and feasibility of SCD in critically ill children. Setting and Participants Four pediatric institutions enrolled children weighing 10 kg or more with AKI and multi-organ dysfunction receiving CRRT as the standard of care with the SCD-integrated post-CRRT membrane. Exposure Patients received CRRT-SCD with regional citrate anticoagulation for up to 7-10 days, or CRRT discontinuation, whichever came first. Analytical Approach We reported serious adverse events among patients and CRRT-SCD-related process and outcome variables. We compared survival to intensive care unit (ICU) discharge rates between the CRRT-SCD cohort and a matched cohort from the prospective pediatric CRRT registry, using odds ratios in multivariable analysis for factors associated with prospective pediatric CRRT patient ICU mortality. To validate these crude analyses, Bayesian logistic regression was performed to assess for attributable benefit-risk assessment of the SCD. Results Twenty-two patients received CRRT-SCD treatments. Fifteen serious adverse events were recorded; none were SCD-related. Seventeen patients survived till ICU discharge or day 60. Both multivariable and Bayesian analyses revealed a probable benefit of the addition of SCD. Fourteen of the 16 patients surviving ICU discharge reported a normal estimated glomerular filtration rate and no patient was dialysis dependent at 60 days. Limitations The study had a few limitations, such as (1) a small sample size in the SCD-PED cohort group; (2) unchanging historic control group; and (3) adverse events were not recorded in the control group. Conclusions The SCD therapy is feasible, safe, and demonstrates probable benefit for critically ill children who require CRRT for AKI.
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Affiliation(s)
- Stuart L. Goldstein
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Nicholas J. Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David J. Askenazi
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rajit K. Basu
- Division of Critical Care Medicine, Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - David T. Selewski
- Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Kelli A. Krallman
- Division of Nephrology & Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lenar Yessayan
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
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Johnston KA, Pino CJ, Chan G, Ketteler SK, Goldstein SL, Humes HD. Immunomodulatory therapy using a pediatric dialysis system ameliorates septic shock in miniature pigs. Pediatr Res 2023; 93:89-96. [PMID: 35501373 PMCID: PMC9626391 DOI: 10.1038/s41390-022-02061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/01/2022] [Accepted: 03/11/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Application of the immunomodulatory selective cytopheretic device (SCD) to enhance renal replacement therapy and improve outcomes of acute kidney injury in pediatric patients is impeded by safety concerns. Therapy using a pediatric hemodialysis system could overcome these limitations. METHODS Yucatan minipigs (8-15 kg) with induced septic shock underwent continuous hemodiafiltration with the CARPEDIEM™ pediatric hemodialysis system using regional citrate anticoagulation (RCA) with or without SCD (n = 5 per group). Circuit function plus hemodynamic and hematologic parameters were assessed for 6 h. RESULTS SCD was readily integrated into the CARPEDIEM™ system and treatment delivered for 6 h without interference with pump operation. SCD-treated pigs maintained higher blood pressure (p = 0.009) commensurate with lesser degree of lactic acidosis (p = 0.008) compared to pigs only receiving hemodiafiltration. Renal failure occurred in untreated pigs while urine output was sustained with SCD therapy. Neutrophil activation levels and ss-SOFA scores at 6 h trended lower in the SCD-treated cohort. CONCLUSIONS SCD therapy under RCA was safely administered using the CARPEDIEM™ pediatric hemodialysis system for up to 6 h and no circuit compatibility issues were identified. Sepsis progression and organ dysfunction was diminished with SCD treatment in this model supportive of therapeutic benefit of this immunomodulatory therapy. IMPACT SCD therapy with regional citrate anticoagulation has the potential to be administered safely to patients weighing <20 kg using the Carpediem renal replacement therapy platform. Use of a renal replacement therapy platform designed specifically for neonates/infants overcomes safety concerns for delivery of SCD treatment in this population. SCD therapy using the Carpediem renal replacement therapy platform retained the suggestive efficacy seen in larger children and adults to reduce organ injury and dysfunction from sepsis.
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Affiliation(s)
- Kimberly A. Johnston
- Department of Internal Medicine, Division of Nephrology University of Michigan Ann Arbor, Michigan,,Innovative Biotherapies, Ann Arbor, Michigan
| | - Christopher J. Pino
- Department of Internal Medicine, Division of Nephrology University of Michigan Ann Arbor, Michigan,,Innovative Biotherapies, Ann Arbor, Michigan
| | - Goldia Chan
- Unit for Laboratory Animal Medicine University of Michigan Ann Arbor, Michigan
| | - Skylar K. Ketteler
- Department of Internal Medicine, Division of Nephrology University of Michigan Ann Arbor, Michigan,,Innovative Biotherapies, Ann Arbor, Michigan
| | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - H. David Humes
- Department of Internal Medicine, Division of Nephrology University of Michigan Ann Arbor, Michigan,,Innovative Biotherapies, Ann Arbor, Michigan,,Corresponding author: H. David Humes M.D. Department of Internal Medicine Division of Nephrology 4520 MSRB I 1150 West Medical Center Drive Ann Arbor MI 48109 office: (734) 763-5120, fax: 734-763-4851.
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Goldstein SL, Askenazi DJ, Basu RK, Selewski DT, Paden ML, Krallman KA, Kirby CL, Mottes TA, Terrell T, Humes HD. Use of the Selective Cytopheretic Device in Critically Ill Children. Kidney Int Rep 2020; 6:775-784. [PMID: 33732992 PMCID: PMC7938071 DOI: 10.1016/j.ekir.2020.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Critically ill children with acute kidney injury (AKI) requiring continuous kidney replacement therapy (CKRT) are at increased risk of death. The selective cytopheretic device (SCD) promotes an immunomodulatory effect when circuit ionized calcium (iCa2+) is maintained at <0.40 mmol/l with regional citrate anticoagulation (RCA). In a randomized trial of adult patients on CRRT, those treated with the SCD maintaining an iCa2+ <0.40 mmol/l had improved survival/dialysis independence. We conducted a US Food and Drug Administration (FDA)–sponsored study to evaluate safety and feasibility of the SCD in 16 critically ill children. Methods Four pediatric intensive care units (ICUs) enrolled children with AKI and multiorgan dysfunction receiving CKRT to receive the SCD integrated post-CKRT membrane. RCA was used to achieve a circuit iCa2+ level <0.40 mmol/l. Subjects received SCD treatment for 7 days or CKRT discontinuation, whichever came first. Results The FDA target enrollment of 16 subjects completed the study from December 2016 to February 2020. Mean age was 12.3 ± 5.1 years, weight was 53.8 ± 28.9 kg, and median Pediatric Risk of Mortality II was 7 (range 2–19). Circuit iCa2+ levels were maintained at <0.40 mmol/l for 90.2% of the SCD therapy time. Median SCD duration was 6 days. Fifteen subjects survived SCD therapy; 12 survived to ICU discharge. All ICU survivors were dialysis independent at 60 days. No SCD-related adverse events (AEs) were reported. Conclusion Our data demonstrate that SCD therapy is feasible and safe in children who require CKRT. Although we cannot make efficacy claims, the 75% survival rate and 100% renal recovery rate observed suggest a possible favorable benefit-to-risk ratio.
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Affiliation(s)
| | | | - Rajit K Basu
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - David T Selewski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Kelli A Krallman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cassie L Kirby
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theresa A Mottes
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tara Terrell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Humes HD, Westover AJ. Experience With Pediatric Medical Device Development. Front Pediatr 2020; 8:79. [PMID: 32318519 PMCID: PMC7154058 DOI: 10.3389/fped.2020.00079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/18/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- H David Humes
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Angela J Westover
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
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Early Sequential Risk Stratification Assessment to Optimize Fluid Dosing, CRRT Initiation and Discontinuation in Critically Ill Children with Acute Kidney Injury: Taking Focus 2 Process Article. JOURNAL OF CLINICAL TRIALS 2020; 10:435. [PMID: 34476130 PMCID: PMC8409431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Acute Kidney Injury (AKI) is common in critically ill children and is associated with increased morbidity and mortality. Recognition and management of AKI is often delayed, predisposing patients to risk of clinically significant fluid accumulation (Fluid Overload (FO)). Early recognition and intervention in high risk patients could decrease fluid associated morbidity. We aim to assess an AKI Clinical Decision Algorithm (CDA) using a sequential risk stratification strategy integrating the Renal Angina Index (RAI), urine Neutrophil Gelatinase-Associated Lipocalin (NGAL) and the Furosemide Stress Test (FST) to optimize AKI and FO prediction and management in critically ill children. METHODS/DESIGN This single center prospective observational cohort study evaluates the AKI CDA in a Pediatric Intensive Care Unit (PICU). Every patient ≥ 3 months old has the risk score RAI calculated automatically at 12 hours of admission. Patients with a RAI ≥ 8 (fulfilling renal angina) have risk further stratified with a urine NGAL and, if positive (NGAL ≥ 150ng/mL), subsequently by their response to a standardized dose of furosemide (namely FST). RAI negative or NGAL negative patients are treated per usual care. FST-responders are managed conservatively, while non-responders receive fluid restrictive strategy and/or continuous renal replacement therapy (CRRT) at 10%-15% of FO. 2100 patients over 3 years will be evaluated to capture 210 patients with severe AKI (KDIGO Stage 2 or 3 AKI), 100 patients with >10% FO, and 50 requiring CRRT. Primary analyses: Standardizing a pediatric FST and assessing prediction accuracy of CDA for severe AKI, FO>10% and CRRT requirement in children. Secondary analyses in patients with AKI: Renal function return to baseline, RRT and mortality within 28 days. DISCUSSION This will be the first prospective evaluation of feasibility of AKI CDA, integrating individual prediction tools in one cohesive and comprehensive approach, and its prediction of FO>10% and AKI, as well as the first to standardize the FST in the pediatric population. This will increase knowledge on current AKI prediction tools and provide actionable insight for early interventions in critically ill children based on their level of risk.
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Pino CJ, Westover AJ, Johnston KA, Buffington DA, Humes HD. Regenerative Medicine and Immunomodulatory Therapy: Insights From the Kidney, Heart, Brain, and Lung. Kidney Int Rep 2018; 3:771-783. [PMID: 29989023 PMCID: PMC6035130 DOI: 10.1016/j.ekir.2017.12.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/21/2017] [Accepted: 12/31/2017] [Indexed: 12/30/2022] Open
Abstract
Regenerative medicine was initially focused on tissue engineering to replace damaged tissues and organs with constructs derived from cells and biomaterials. More recently, this field of inquiry has expanded into exciting areas of translational medicine modulating the body’s own endogenous processes, to prevent tissue damage in organs and to repair and regenerate these damaged tissues. This review will focus on recent insights derived from studies in which the manipulation of the innate immunologic system may diminish acute kidney injury and enhance renal repair and recovery without the progression to chronic kidney disease and renal failure. The manner in which these interventions may improve acute and chronic organ dysfunction, including the heart, brain, and lung, will also be reviewed.
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Affiliation(s)
| | | | | | | | - H David Humes
- Innovative BioTherapies, Inc., Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,CytoPherx, Inc., Ann Arbor, Michigan, USA
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