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Terada-Hirashima J, Izumi S, Katagiri D, Uemura Y, Mikami A, Sugiura W, Abe S, Azuma A, Sugiyama H. Efficacy and Safety of Direct Hemoperfusion using Polymyxin B-Immobilized Polystyrene Column (PMX-DHP) for COVID-19 Patients: Exploratory Study Protocol. JMIR Res Protoc 2022; 11:e37426. [PMID: 36126219 DOI: 10.2196/37426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/28/2022] [Accepted: 09/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Polymyxin B-immobilized fiber column (PMX, Toraymyxin column) was approved for the relief of SIRS (systemic inflammatory response syndrome) caused by bacterial infection or endotoxemia. PMX reduces lung damage by removing leukocytes and cytokines in addition to endotoxin removal, in the setting of idiopathic pulmonary fibrosis. Acute exacerbation of interstitial pneumonia pathologically presents with diffuse alveolar damage (DAD). PMX direct hemoperfusion (PMX-DHP) demonstrated efficacy, improving oxygenation. SARS-CoV-2 virus causes COVID-19 pneumonia that emerged in December 2019. The condition may become severe about 1 week after onset, and respiratory failure rapidly develops, requiring intensive care management. A characteristic of COVID-19-related severe pneumonia is ground-glass opacities rapidly progressing in both lungs, which subsequently turn into infiltrative shadows. This condition could be classified as DAD. As for the congealing fibrinogenolysis system, D-dimer, fibrin/fibrinogen degradation product quantity and prolonged prothrombin time were significant factors in non-surviving COVID-19 cases, associated with aggravated pneumonia. Clinical trials are being conducted but, with the exception of remdesivir and dexamethasone, no treatments have yet been approved. COVID-19 aggravates with the deterioration of oxygen saturation, decrease in lymphocytes and the occurrence of an abnormal congealing fibrinogenolysis system, leading to diffuse lung damage. Once the condition transitions from moderate to severe, it is most necessary to prevent further exacerbation by providing treatment that will suppress the above symptoms as soon as possible. OBJECTIVE To acquire treatment options to prevent the transition from acute exacerbation of interstitial pneumonia to DAD. The mechanism of action envisioned for PMX-DHP is to reduce congealing fibrinogenolysis system abnormalities and increase oxygenation by removing activated leucocytes and cytokines, which are risk factors for the aggravation of COVID-19-related pneumonia. METHODS We will conduct a multicenter prospective intervention single-group study to evaluate the efficacy and safety of direct hemoperfusion using PMX-DHP for COVID-19 patients. Efficacy will be evaluated by the primary endpoint, which is the rate of Ordinal Scale for Clinical Improvement after PMX-DHP of at least 1 point from a status of 4.5.6 on Day 15. The effect of PMX-DHP will be estimated by setting a control group with background factors from non-PMX-DHP patients enrolled in the COVID-19 registry. This study will be carried out as a single-group open-label study and will be compared with a historical control. The historical control will be selected from the COVID-19 registry according to age, gender, and severity of pneumonia. RESULTS This study will help determine PMX-DHP treatment options in the medical setting by quickly collecting and publishing information on patient background and on the efficacy and safety of treatment by PMX-DHP. CONCLUSIONS From a clinical perspective, PMX-DHP is expected to become a first-line therapy to address unmet medical needs and prevent the exacerbation from moderate to severe ARDS (acute respiratory distress syndrome) in COVID-19 cases. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/37426.
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Affiliation(s)
- Junko Terada-Hirashima
- Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-ku, Tokyo, JP
| | - Shinyu Izumi
- Department of Pulmonary Medicine, Center Hospital of the National Center for Global Health and Medicine,, Tokyo, JP
| | - Daisuke Katagiri
- Department of Nephrology, Center Hospital of the National Center for Global Health and Medicine, Tokyo, JP
| | - Yukari Uemura
- Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-ku, Tokyo, JP
| | - Ayako Mikami
- Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-ku, Tokyo, JP
| | - Wataru Sugiura
- Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku-ku, Tokyo, JP
| | - Shinji Abe
- Department of Pulmonary Medicine, Tokyo Medical University Hospital, Tokyo, JP
| | - Arata Azuma
- Department of Pulmonary medicine and oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, JP
| | - Haruhito Sugiyama
- Department of Pulmonary Medicine, Center Hospital of the National Center for Global Health and Medicine,, Tokyo, JP
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Peerapornratana S, Sirivongrangson P, Tungsanga S, Tiankanon K, Kulvichit W, Putcharoen O, Kellum JA, Srisawat N. Endotoxin Adsorbent Therapy in Severe COVID-19 Pneumonia. Blood Purif 2021; 51:47-54. [PMID: 33857940 PMCID: PMC8089445 DOI: 10.1159/000515628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 03/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uncontrolled systemic inflammation may occur in severe coronavirus disease 19 (COVID-19). We have previously shown that endotoxemia, presumably from the gut, may complicate COVID-19. However, the role of endotoxin adsorbent (EA) therapy to mitigate organ dysfunction in COVID-19 has not been explored. METHODS We conducted a retrospective observational study in COVID-19 patients who received EA therapy at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between March 13 and April 17, 2020. Relevant clinical and laboratory data were collected by inpatient chart review. RESULTS Among 147 hospitalized COVID-19 patients, 6 patients received EA therapy. All of the 6 patients had severe COVID-19 infection with acute respiratory distress syndrome (ARDS). Among these, 5 of them were mechanically ventilated and 4 had complications of secondary bacterial infection. The endotoxin activity assay (EAA) results of pre-EA therapy ranged from 0.47 to 2.79. The choices of EA therapy were at the discretion of attending physicians. One patient was treated with oXiris® along with continuous renal replacement therapy, and the others received polymyxin B hemoperfusion sessions. All patients have survived and were finally free from the mechanical ventilation as well as had improvement in PaO2/FiO2 ratio and decreased EAA level after EA therapy. CONCLUSIONS We demonstrated the clinical improvement of severe COVID-19 patients with elevated EAA level upon receiving EA therapy. However, the benefit of EA therapy in COVID-19 ARDS is still unclear and needs to be elucidated with randomized controlled study.
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Affiliation(s)
- Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Phatadon Sirivongrangson
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanitha Tiankanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Win Kulvichit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Opass Putcharoen
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - John A. Kellum
- Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand
- Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
- Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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