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Yildiz AB, Copur S, Tanriover C, Yavuz F, Vehbi S, Hasbal NB, Kanbay M. A potential approach toward the management of sepsis: The extracorporeal cytokine hemadsorption therapy. Semin Dial 2024; 37:117-121. [PMID: 38084784 DOI: 10.1111/sdi.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 11/11/2023] [Accepted: 11/20/2023] [Indexed: 03/16/2024]
Abstract
Infectious diseases are among the most common cause of morbidity and mortality among hospitalized patients while systemic inflammatory response syndrome is primarily attributed to the imbalance between pro-inflammatory and anti-inflammatory cytokines. Despite the improvements in the antibiotherapy alternatives and diagnostic modalities, the morbidity and mortality rates of sepsis and septic shock are relatively high among patients admitted to the intensive care units. Extracorporeal cytokine hemadsorption therapies are therapeutic approaches for such patient group with promising early results that especially have grown during COVID-19 pandemic. In this narrative review, our aim is to evaluate the current pre-clinical and clinical knowledge regarding the use of cytokine filtration systems among patients with septic shock.
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Affiliation(s)
| | - Sidar Copur
- Department of Internal Medicine, School of Medicine, Koc University, Istanbul, Turkey
| | - Cem Tanriover
- School of Medicine, Koc University, Istanbul, Turkey
| | - Furkan Yavuz
- School of Medicine, Koc University, Istanbul, Turkey
| | - Sezan Vehbi
- School of Medicine, Koc University, Istanbul, Turkey
| | - Nuri Baris Hasbal
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Koc University, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Koc University, Istanbul, Turkey
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Tomescu D, Popescu M, Akil A, Nassiri AA, Wunderlich-Sperl F, Kogelmann K, Molnar Z, Alharthy A, Karakitsos D. The potential role of extracorporeal cytokine removal with CytoSorb® as an adjuvant therapy in Acute Respiratory Distress Syndrome. Int J Artif Organs 2023; 46:605-617. [PMID: 38037333 DOI: 10.1177/03913988231211740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Management of acute respiratory distress syndrome (ARDS) represents one of the greatest challenges in intensive care and despite all efforts mortality remains high. One common phenotype of ARDS is that of a secondary injury to a dysregulated inflammatory host response resulting in increased capillary congestion, interstitial lung edema, atelectasis, pulmonary embolism, muscle wasting, recurring infectious episodes, and multiple organ failure. In cases of hyperinflammation, immunomodulation by extracorporeal cytokine removal such as the CytoSorb hemoadsorption cartridge could conceptually enhance lung recovery during the early course of the disease. The aim of this narrative review is to summarize the currently available data in this field and to provide an overview of pathophysiology and rationale for the use of CytoSorb hemoadsorption in patients with hyperinflammatory ARDS.
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Affiliation(s)
- Dana Tomescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Department of Anaesthesia and Intensive Care, Bucharest, Romania
| | - Mihai Popescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Department of Anaesthesia and Intensive Care, Bucharest, Romania
| | - Ali Akil
- Department of Thoracic Surgery, Hans Susemihl Hospital Emden, Emden, Germany
| | - Amir Ahmad Nassiri
- Division of Nephrology, Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Florian Wunderlich-Sperl
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Klaus Kogelmann
- Department of Anesthesiology and Intensive Care Medicine, Hans Susemihl Hospital Emden, Emden, Germany
| | - Zsolt Molnar
- CytoSorbents Europe GmbH, Berlin, Germany
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Dimitrios Karakitsos
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- Critical Care Department, Keck School of Medicine, USC, Los Angeles, CA, USA
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Becker S, Lang H, Vollmer Barbosa C, Tian Z, Melk A, Schmidt BMW. Efficacy of CytoSorb®: a systematic review and meta-analysis. Crit Care 2023; 27:215. [PMID: 37259160 PMCID: PMC10230475 DOI: 10.1186/s13054-023-04492-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/15/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Cytokine adsorption using the CytoSorb® adsorber has been proposed in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or recovery after cardiac arrest. The aim of this analysis is to provide evidence for the efficacy of the CytoSorb® adsorber with regard to mortality in various settings. METHODS We searched PubMed, Cochrane Library database and the database provided by Cytosorbents™ (01.1.2010-29.5.2022). We considered randomized controlled trials and observational studies with control groups. The longest reported mortality was defined as the primary endpoint. We computed risk ratios and 95%-confidence intervals and used DerSimonian and Lairds random effects model. We analysed all studies combined and divided them into the subgroups: sepsis, cardiopulmonary bypass surgery (CPB), other severe illness, SARS-CoV-2 infection and recovery from cardiac arrest. The meta-analysis was registered in advance (PROSPERO: CRD42022290334). RESULTS Of an initial 1295 publications, 34 studies were found eligible, including 1297 patients treated with CytoSorb® and 1314 controls. Cytosorb® intervention did not lower mortality (RR [95%-CI]: all studies 1.07 [0.88; 1.31], sepsis 0.98 [0.74; 1.31], CPB surgery 0.91 [0.64; 1.29], severe illness 0.95 [0.59; 1.55], SARS-CoV-2 1.58 [0.50; 4.94]). In patients with cardiac arrest, we found a significant survival advantage of the untreated controls (1.22 [1.02; 1.46]). We did not find significant differences in ICU length of stay, lactate levels, or IL-6 levels after treatment. Of the eligible 34 studies only 12 were randomized controlled trials. All observational studies showed moderate to serious risk of bias. INTERPRETATION To date, there is no evidence for a positive effect of the CytoSorb® adsorber on mortality across a variety of diagnoses that justifies its widespread use in intensive care medicine.
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Affiliation(s)
- Sören Becker
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Hannah Lang
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Clara Vollmer Barbosa
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Zhejia Tian
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Ghasemi K, Ghasemi K. Evaluation of the Tocilizumab therapy in human cancers: Latest evidence and clinical potential. J Clin Pharm Ther 2022; 47:2360-2368. [PMID: 36271617 DOI: 10.1111/jcpt.13781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/20/2022] [Accepted: 09/04/2022] [Indexed: 12/24/2022]
Abstract
Tocilizumab (Actemra®), as the first human interleukin-6 receptor (IL-6R) antagonist, has been used in treating moderate to severe active rheumatoid arthritis (RA) patients who were undertreatment with one or more disease-modifying anti-rheumatic drugs (DMARDs) and did not improve significantly. Tocilizumab also has been administrated and confirmed in several inflammatory-based diseases. Recently, tocilizumab has been prescribed to treat patients with advanced coronavirus disease (COVID-19) and is used as one of the effective drugs in reducing the increased inflammation in these patients. On the other hand, cancer treatment has been considered by researchers one of the most important challenges to human health. Regarding inflammatory-associated malignancies, it has been shown that inflammatory mediators such as interleukin-1 beta (IL-1β), IL-6, and tumour necrosis factor-alpha (TNF-α) may play a role in tumorigenesis, thus targeting these cytokines as evidence suggested can be useful in the treatment of these types of cancers. This review summarized the role of the IL-6/IL-6R axis in inflammation-based cancers and discussed the effectiveness and challenges of treating cancer with tocilizumab.
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Affiliation(s)
- Kimia Ghasemi
- Department of Pharmacology and Toxicology, School of Pharmacy; Fertility and Infertility Research Center, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kosar Ghasemi
- Department of Pharmacology and Toxicology, School of Pharmacy; Cellular and Molecular Research Center, Jundishapur University of Medical Sciences, Ahvaz, Iran
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Apheresis and COVID-19 in intensive care unit (ICU). Transfus Apher Sci 2022; 61:103593. [PMID: 36335074 PMCID: PMC9624107 DOI: 10.1016/j.transci.2022.103593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. The disease has since spread worldwide, and on March 2020 the World Health Organization (WHO) declared it as pandemic, causing a public health crisis. Symptoms of COVID-19 are variable, ranging from mild symptoms like fever, cough, and fatigue to severe illness. Elderly patients and those with comorbidities like cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop severe forms of the disease. Asymptomatic infections have been well documented. Accumulating evidence suggests that the severity of COVID-19 is due to high levels of circulating inflammatory mediators including cytokines and chemokines leading to cytokine storm syndrome (CSS). Patients are admitted in ICU with severe respiratory failure, but can also develop acute renal failure and multi organ failure. Advances in science and technology have permitted the development of more sophisticated therapies such as extracorporeal organ support (ECOS) therapies that includes renal replacement therapies (RRTs), venoarterial (VA) or veno-venous (VV) extracorporeal membrane Oxygenation (ECMO), extracorporeal CO2 removal (ECCO2R), liver support systems, hemoperfusion, and various blood purification devices, for the treatment of ARDS and septic shock.
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Rodeia SC, Martins FL, Fortuna P, Bento L. Cytokine Adsorption Therapy during Extracorporeal Membrane Oxygenation in Adult Patients with COVID-19. Blood Purif 2021; 51:791-798. [PMID: 34856539 PMCID: PMC8805080 DOI: 10.1159/000518712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 07/18/2021] [Indexed: 11/30/2022]
Abstract
Respiratory failure and systemic inflammation are paramount features of severe SARS-CoV-2 disease (COVID-19). Extracorporeal membrane oxygenation (ECMO) therapy has a potential role in patients with refractory disease. An inflammatory response due to blood contact with hemofilters, functioning as a synergic inflammatory stimulus, can lead to a hyperinflammatory state, relatable to cytokine release syndromes. After the first patient succumbed to a refractory vasodilatory shock believed to be due to hyperinflammatory state, a strategy of blood purification through cytokine adsorption therapy (CAT) with CytoSorb® was designed. In this case series, the authors describe the initial experience with such strategy. CAT was employed with no direct complications and helped controlling the inflammatory state, with all patients halting vasopressor support in 72 h and biomarker levels (C-reactive protein, ferritin, and interleukin-6) showing negative trends in most patients. Analysis of inflammatory biomarkers evolution highlighted 2 biomarker profiles related to the presence or absence of superinfection at the time of CAT implementation. In this case series of severe COVID-19 patients, 3 patients died − irreversible lung fibrosis, complications of critical hypoxemia before ECMO induction and complications of systemic anticoagulation were the causes. This case series aimed to contribute to the body of evidence substantiating CAT utilization in hyperinflammatory patients, namely, COVID-19 patients requiring ECMO rescue.
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Affiliation(s)
- Simão C Rodeia
- Unidade de Urgência Médica (General ICU), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Francisca Lopes Martins
- Unidade de Urgência Médica (General ICU), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Philip Fortuna
- Unidade de Urgência Médica (General ICU), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Luís Bento
- Unidade de Urgência Médica (General ICU), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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Ruiz-Rodríguez JC, Molnar Z, Deliargyris EN, Ferrer R. The Use of CytoSorb Therapy in Critically Ill COVID-19 Patients: Review of the Rationale and Current Clinical Experiences. Crit Care Res Pract 2021; 2021:7769516. [PMID: 34336280 PMCID: PMC8324379 DOI: 10.1155/2021/7769516] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/08/2021] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has led to the biggest global health crisis of our lifetime. There is accumulating evidence that a substantial number of critically ill COVID-19 patients exhibit a dysregulated host response manifesting as cytokine storm or cytokine release syndrome, which in turn contributes to the high observed rates of mortality. Just as in other hyperinflammatory conditions, extracorporeal cytokine removal may have potential beneficial effects in this subgroup of COVID-19 patients. The CytoSorb blood purification device is the most extensively investigated cytokine removal platform with considerable evidence suggesting that early intervention can provide rapid hemodynamic stabilization and improvement in vital organ functions. The purpose of this review is to provide an overview of the pathophysiological background of hyperinflammation in COVID-19 and to summarize the currently available evidence on the effects of hemoadsorption in these patients.
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Affiliation(s)
- Juan Carlos Ruiz-Rodríguez
- Department of Intensive Care, Hospital Universitari Vall d'Hebron, Shock Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Zsolt Molnar
- CytoSorbents Europe GmbH, Berlin, Germany
- Institute for Translational Medicine, School of Medicine, University of Pécs, Pécs, Hungary
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Ricard Ferrer
- Department of Intensive Care, Hospital Universitari Vall d'Hebron, Shock Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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Wunderlich-Sperl F, Kautzky S, Pickem C, Hörmann C. Adjuvant hemoadsorption therapy in patients with severe COVID-19 and related organ failure requiring CRRT or ECMO therapy: A case series. Int J Artif Organs 2021; 44:694-702. [PMID: 34256643 DOI: 10.1177/03913988211030517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe cases of the COVID-19 are often associated with the development of a fulminant sepsis-like state with a concomitant cytokine release syndrome. Recently, immunomodulating approaches to treat such a hyperinflammation have come into focus, including the use of new extracorporeal organ support therapies such as CytoSorb hemoadsorption designed to remove cytokines and other circulating mediators from blood. PATIENTS AND METHODS Thirteen critically ill COVID-19 patients with ARDS who received either ECMO therapy and/or CRRT with concomitant multiple organ failure were included. Hemoadsorption therapy was initiated once the patient had established-or was at high risk of developing-a hyperinflammatory state with marked hemodynamic instability or progressive lung failure. Levels of inflammatory markers, vasopressor requirements, oxygenation, and ventilation parameters were measured, as well as clinically relevant outcome measures. RESULTS Combined therapy was associated with a significant reduction in inflammatory mediators, hemodynamic stabilization with a concomitant decrease in requirements for vasoactive substances, and a pronounced improvement in lung function and the need for ventilatory support. Treatment appeared safe and well-tolerated. CONCLUSIONS In this case series of SARS-CoV-2 infected patients admitted to the intensive care unit with ARDS, we report effective interleukin (IL)-6 removal, reduced norepinephrine requirement, and improved lung function while receiving adjuvant, extracorporeal hemoadsorption therapy in the context of a multimodal treatment approach. The presented protocol for CytoSorb initiation may be a good foundation for the development of further prospective studies in the field and may eventually also be applied to other forms of hyperinflammatory ARDS.
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Affiliation(s)
- Florian Wunderlich-Sperl
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Sebastian Kautzky
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Christian Pickem
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
| | - Christoph Hörmann
- Clinical Department of Anesthesiology and Intensive Care Medicine, University Hospital St. Pölten-Lilienfeld, St. Pölten, Austria
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Kornitzky FW, Langen HJ, Held M. [Treatment of a Patient with a Pronounced Cytokine Storm in Severe COVID-19 Pneumonia using a Hemoadsorption in Combination with the Administration of tocilizumab]. Pneumologie 2021; 75:644-650. [PMID: 33882609 DOI: 10.1055/a-1458-4080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite growing experience due to increasing patient numbers, the intensive care treatment of patients with severe COVID-19 pneumonia continues to be a particular challenge in individual cases, which may also therefore legitimize individualized therapeutic attempts. In this context, the so-called hyperinflammation syndrome characterized by a cytokine storm accompanied by a massive increase in inflammatory markers such as interleukin(IL)-6, represents such a situation. This case report describes the therapeutic approach of using the IL-6-specific antibody tocilizumab in combination with hemoadsorption therapy (CytoSorb) in a 58-year-old male patient with severe COVID-19 pneumonia. The patient suffered a massive clinical deterioration with concomitant Horovitz index of 127 mmHg that occurred on the 6th day of ventilation. After combined application of the above-mentioned therapeutic approaches, the patient stabilized rapidly paralleled by a significant increase in the Horovitz index, and the possibility of de-escalating the ventilation regimen, which ultimately enabled successful extubation after only 13 days of ventilation. Moreover, the combined treatment was associated with significant hemodynamic stabilization and a consecutive reduction in vasopressor doses, while hyperinflammation could be kept well under control. The incorporation of the hemoadsorber into the therapeutic regimen proved to be safe and straightforward. In conclusion, the combination of CytoSorb therapy and IL-6 blockade by tocilizumab appeared, at least in this case, to be an effective measure to modulate an overshooting immune response in COVID-19 pneumonia with a concomitant clinical improvement in both respiratory and hemodynamic function, and thus could be used as a potential therapeutic option in this clinical picture.
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Affiliation(s)
- F W Kornitzky
- Klinikum Würzburg Mitte gGmbH, Standort Missioklinik, Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin
| | - H-J Langen
- Klinikum Würzburg Mitte gGmbH, Standort Missioklinik, Institut für Radiologie
| | - M Held
- Klinikum Würzburg Mitte gGmbH, Standort Missioklinik, Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin
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