1
|
Siew LY, Lee ZY, Yunos NM, Atan R, Cove ME, Lumlertgul N, Srisawat N, Hasan MS. Outcomes of extracorporeal blood purification with oXiris® membrane in critically ill patients: A systematic review and meta-analysis. J Crit Care 2024; 83:154844. [PMID: 38901069 DOI: 10.1016/j.jcrc.2024.154844] [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] [Received: 11/02/2023] [Revised: 04/26/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE To evaluate the efficacy of the novel oXiris® membrane in critically ill adult patients. METHODS We systematically searched MEDLINE, EMBASE, and CENTRAL from inception to 01/06/2023 for relevant randomised controlled trials (RCTs) and non-randomised studies of intervention (NRSI). The primary outcome was overall mortality. Random effect meta-analyses were conducted in RevMan 5.4.1. Study quality was evaluated using Cochrane's risk of bias tool. (PROSPERO: CRD42023389198). RESULTS Ten studies (2 RCTs and 8 NRSIs) with 481 patients were included. None had low risk of bias. Treatment using oXiris® was associated with reduced overall mortality (RR 0.78, 95%CI 0.62-0.98; p = 0.03; 6 NRSI). One RCT reported 28-day mortality, finding no significant difference between groups. Besides, pooled NRSIs results showed significant reductions in SOFA scores, norepinephrine dosage, and several inflammatory biomarkers (C-reactive protein [CRP], lactate, and interleukin-6 [IL-6]) post oXiris® treatment. However, other clinical outcomes (ICU and hospital length of stay, mechanical ventilation duration) were similar between groups. CONCLUSION In critically ill patients, the use of oXiris® membrane was associated with reduced overall mortality, norepinephrine dosage, CRP, IL-6, lactate levels, along with improved organ function. However, the certainty of evidence was very low, necessitating high-quality RCTs to further evaluate its efficacy in this population.
Collapse
Affiliation(s)
- Li Ying Siew
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Nor'azim Mohd Yunos
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rafidah Atan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Matthew Edward Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Nuttha Lumlertgul
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia; Department of Anaesthesiology, Universiti Malaya Medical Centre, Kuala Lumpur, Malaysia.
| |
Collapse
|
2
|
Bernard A, Koeppen M. [Extracorporeal procedures in sepsis]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01464-8. [PMID: 39331071 DOI: 10.1007/s00101-024-01464-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Sepsis and septic shock are frequent and severe clinical pictures in intensive care medicine that result from a dysregulated immune response to an infection and cause a high mortality rate. This article provides an overview of the various extracorporeal procedures used to treat sepsis. Various procedures are used to treat sepsis and septic shock. These include high-volume hemofiltration (HVHF), very high-volume hemofiltration (VHVHF), high cut-off filter (HCO), polymyxin B hemoperfusion and cytokine adsorption filters. The HVHF and VHVHF remove inflammatory mediators but show no significant benefit in terms of stabilization and survival in sepsis patients. The HCO filters effectively eliminate cytokines but so far there is no evidence of a survival benefit. Polymyxin B hemoperfusion shows promising results in initial studies in certain patient groups, while evidence for cytokine adsorption filters is limited. Combined plasma filtration and adsorption (CPFA) and therapeutic plasma exchange (TPE) have so far shown promising results in small studies. Although CPFA shows no survival benefit, TPE may have protective effects on the vascular glycocalyx. Extracorporeal procedures carry risks such as thrombosis and loss of proteins and clotting factors. The therapeutic benefit of these procedures in the treatment of sepsis remains unclear and further prospective randomized multicenter studies are needed to evaluate their efficacy and safety. There are currently no guideline recommendations for the routine use of these procedures in sepsis.
Collapse
Affiliation(s)
| | - Michael Koeppen
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Eberhard-Karls-Universität Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Deutschland.
| |
Collapse
|
3
|
Hillebrand U, Rex N, Seeliger B, Stahl K, Schenk H. [What is confirmed in the treatment of sepsis? : An update]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024:10.1007/s00108-024-01794-0. [PMID: 39320478 DOI: 10.1007/s00108-024-01794-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/30/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Sepsis is defined as "being evoked as a life-threatening organ dysfunction caused by an inadequate host response to infection". The most recent German S3 guidelines were published in 2018 and the Surviving Sepsis Campaign (SSC) last published the current recommendations for the treatment of sepsis and septic shock in 2021. OBJECTIVE This article explores and discusses which evidence in the treatment of sepsis and septic shock has been confirmed. MATERIAL AND METHODS Discussion of the 2018 German S3 guidelines, supplementation of the content of the 2021 international guidelines and recent research results since 2021. RESULTS The primary objective for managing sepsis and septic shock still includes rapid identification, early initiation of anti-infective treatment, and focus cleansing when feasible. In addition, the focus is on hemodynamic stabilization, including the early use of vasopressors for prevention of hypervolemia and, if necessary, the use of organ support procedures. Supportive treatment, such as the administration of corticosteroids and the use of apheresis, can be advantageous in specific scenarios. The focus is increasingly shifting towards post-intensive care unit (ICU) follow-up care, improving the quality of life after surviving sepsis and the close involvement of relatives of the patient. CONCLUSION Despite the fact that considerable progress has been made in understanding the pathophysiology and treatment of sepsis, the early administration of anti-infective agents, focus control, nuanced volume therapy and the use of catecholamines continue to be fundamental to sepsis management. New recommendations emphasize the early use of vasopressors (primarily norepinephrine) and the administration of corticosteroids, especially in cases of septic shock and pneumonia.
Collapse
Affiliation(s)
- Uta Hillebrand
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Nikolai Rex
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Benjamin Seeliger
- Klinik für Pneumologie und Infektiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Klaus Stahl
- Klinik für Gastroenterologie, Hepatologie, Infektiologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Heiko Schenk
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| |
Collapse
|
4
|
Graf H, Gräfe C, Bruegel M, Happich FL, Wustrow V, Wegener A, Wilfert W, Zoller M, Liebchen U, Paal M, Scharf C. Extracorporeal Elimination of Pro- and Anti-inflammatory Modulators by the Cytokine Adsorber CytoSorb ® in Patients with Hyperinflammation: A Prospective Study. Infect Dis Ther 2024; 13:2089-2101. [PMID: 39154299 PMCID: PMC11343926 DOI: 10.1007/s40121-024-01028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/30/2024] [Indexed: 08/19/2024] Open
Abstract
INTRODUCTION The release of pro-inflammatory cytokines in critically ill patients with sepsis leads to endothelial dysfunction resulting in cardiocirculatory insufficiency. Their extracorporeal elimination using the cytokine adsorber CytoSorb® (CS) (adsorption of especially hydrophobic molecules < 60 kDa) might be promising, but data about the adsorption capacity as well as a potential harmful adsorption of anti-inflammatory cytokines are missing so far. METHODS The prospective Cyto-SOLVE-study included 15 patients with sepsis or other hyperinflammatory conditions (interleukin 6 > 500 pg/ml), continuous kidney replacement therapy, and the application of CS. Various cytokines and chemokines were measured pre- and post-CS as well as in patients' blood at predefined timepoints. Significant changes in the concentrations were detected with the Wilcoxon test with associated samples. Clearance of the adsorber (ml/min) was calculated with: b l o o d f l o w ∗ c o n c e n t r a t i o n p r e - p o s t c o n c e n t r a t i o n pre . RESULTS: Most of the inflammatory mediators showed a high initial extracorporeal clearance of 70-100 ml/min after CS installation, which dropped quickly to 10-30 ml/min after 6 h of treatment. No difference in clearance was observed between pro- and anti-inflammatory cytokines. Despite extracorporeal adsorption, a significant (p < 0.05) decrease in the blood concentration after 6 h was only observed for the pro-inflammatory cytokines tumor necrosis factorα (TNF-α) (median 284 vs. 230 pg/ml), vascular endothelial growth factor (VEGF) (median 294 vs. 252 pg/ml), macrophage inflammatory protein 1a (MIP-1a) (median 11.1 vs. 9.0 pg/ml), and regulated upon activation, normal T cell expressed and secreted (RANTES) (median 811 vs. 487 pg/ml) as well as the anti-inflammatory cytokines interleukin 4 (median 9.3 vs. 6.4 pg/ml), interleukin 10 (median 88 vs. 56 pg/ml), and platelet-derived growth factor (PDGF) (median 177 vs. 104 pg/ml). A significant (p < 0.05) decrease in patients' blood after 12 h was only detected for interleukin 10. CONCLUSIONS CS can adsorb pro- as well as anti-inflammatory mediators with no relevant difference regarding the adsorption rate. A fast saturation of the adsorber resulted in a rapid decrease of the clearance. The potential clinical benefit or harm of this unspecific cytokine adsorption needs to be evaluated in the future. TRIAL REGISTRATION ClinicalTrials.gov NCT04913298, registration date June 4, 2021.
Collapse
Affiliation(s)
- Helen Graf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Caroline Gräfe
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Mathias Bruegel
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Felix L Happich
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Vassilissa Wustrow
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Aljoscha Wegener
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | | | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
| |
Collapse
|
5
|
Shen Y. CVVHDF combined with cytokine adsorption column ameliorates severe catheter-related bloodstream infection in a hemodialysis patient. SAGE Open Med Case Rep 2024; 12:2050313X241272670. [PMID: 39185073 PMCID: PMC11342434 DOI: 10.1177/2050313x241272670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/15/2024] [Indexed: 08/27/2024] Open
Abstract
In extracorporeal circulation, inflammatory mediators are eliminated through inflammatory cytokine adsorption. By interacting with inflammatory cytokines and removing them from the bloodstream, the adsorber's adsorbent lowers levels of inflammatory mediators and the inflammatory response. We present the case of a 67-year-old Chinese man diagnosed with sepsis due to a bloodstream infection from a catheter. We promptly utilized a cytokine adsorption column in conjunction with continuous veno-venous hemodiafiltration (CVVHDF), resulting in a decrease in interleukin-6 levels and complete removal of bascteria from the bloodstream. A critical turning point in illness management is reached as the levels of inflammatory cytokines drop and the dosage of patients' vasoactive medications improves significantly. In hemodialysis patients with secondary septic shock in the context of catheter-associated bacteremia, the combination of CVVHDF with cytokine adsorption therapy in hemodialysis may be clinically useful and improve or accelerate the patient's improvement.
Collapse
Affiliation(s)
- Yingjing Shen
- Department of Nephrology, Shanghai Tianyou Hospital, Shanghai, China
| |
Collapse
|
6
|
Schaer DJ, Schaer CA, Humar R, Vallelian F, Henderson R, Tanaka KA, Levy JH, Buehler PW. Navigating Hemolysis, Hemoglobin Toxicity, and Its Renal Implications in Cardiac Surgery. Anesthesiology 2024:141893. [PMID: 39159287 DOI: 10.1097/aln.0000000000005109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
Cardiopulmonary bypass–induced hemolysis is linked to acute kidney injury in cardiac surgery. Emerging therapies targeting cell-free hemoglobin (CFHb), like haptoglobin, nitric oxide (NO), and antioxidants, show promise in reducing kidney injury, highlighting the need for further research.
Collapse
Affiliation(s)
- Dominik J Schaer
- Department of Internal Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christian A Schaer
- Institute of Anesthesiology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Rok Humar
- Department of Internal Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Florence Vallelian
- Department of Internal Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Reney Henderson
- Division of Cardiovascular Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Paul W Buehler
- Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, and Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
7
|
Himmelein S, Perez Ruiz de Garibay A, Brandel V, Zierfuß F, Bingold TM. The ADVanced Organ Support (ADVOS) hemodialysis system removes IL-6: an in vitro proof-of-concept study. Intensive Care Med Exp 2024; 12:66. [PMID: 39083101 PMCID: PMC11291793 DOI: 10.1186/s40635-024-00652-5] [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: 04/17/2024] [Accepted: 07/21/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND IL-6 is a pleiotropic cytokine modulating inflammation and metabolic pathways. Its proinflammatory effect plays a significant role in organ failure pathogenesis, commonly elevated in systemic inflammatory conditions. Extracorporeal blood purification devices, such as the Advanced Organ Support (ADVOS) multi hemodialysis system, might offer potential in mitigating IL-6's detrimental effects, yet its efficacy remains unreported. METHODS We conducted a proof-of-concept in vitro study to assess the ADVOS multi system's efficacy in eliminating IL-6. Varying concentrations of IL-6 were introduced into a swine blood model and treated with ADVOS multi for up to 12 h, employing different blood and concentrate flow rates. IL-6 reduction rate, clearance, and dynamics in blood and dialysate were analyzed. RESULTS IL-6 clearance rates of 0.70 L/h and 0.42 L/h were observed in 4 and 12-h experiments, respectively. No significant differences were noted across different initial concentrations. Reduction rates ranged between 40 and 46% within the first 4 h, increasing up to 72% over 12 h, with minimal impact from flow rate variations. Our findings suggest that an IL-6-albumin interaction and convective filtration are implicated in in vitro IL-6 elimination with ADVOS multi. CONCLUSIONS This study demonstrates for the first time an efficient and continuous in vitro removal of IL-6 by ADVOS multi at low blood flow rates. Initial concentration-dependent removal transitions to more consistent elimination over time. Further clinical investigations are imperative for comprehensive data acquisition.
Collapse
Affiliation(s)
| | | | - Veronika Brandel
- Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Frank Zierfuß
- Department of Internal Medicine, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | | |
Collapse
|
8
|
Kurnik M, Peter F, Matej P. Tocilizumab and CytoSorb for delayed severe cytokine release syndrome after ipilimumab plus nivolumab immunotherapy. Immunotherapy 2024:1-11. [PMID: 39016056 DOI: 10.1080/1750743x.2024.2370180] [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: 11/30/2023] [Accepted: 06/17/2024] [Indexed: 07/18/2024] Open
Abstract
Cytokine release syndrome (CRS) is immune dysregulation phenomenon that is associated with immune checkpoint inhibitors. It is still difficult to distinguish CRS from other dangerous, acute and life-threatening medical disorders.We present a case of delayed grade 4 CRS following treatment of lung adenocarcinoma with ipilimumab plus nivolumab that warranted intensive care level treatment with abundant fluid resuscitation, two-tire vasopressor support, high-flow nasal oxygenation, corticosteroids in high dosages, as well as sustained low-efficiency daily diafiltration with CytoSorb hemadsorption and tocilizumab. Initial treatment of presumed septic shock of unknown origin did not yield results.After initiation of corticosteroids and particularly CytoSorb hemadsorption and tocilizumab, prompt clinical and laboratory improvement was observed.
Collapse
Affiliation(s)
- Marko Kurnik
- General Hospital Celje, Department of Internal Intensive Medicine, Celje, Slovenia
| | - Fazarinc Peter
- General Hospital Celje, Department of Hematology & Oncology, Celje, Slovenia
| | - Podbregar Matej
- General Hospital Celje, Department of Internal Intensive Medicine, Celje, Slovenia
- University of Ljubljana, Medical Faculty, Ljubljana, Slovenia
| |
Collapse
|
9
|
Rabøl Andersen L, Hindsberger B, Bastrup Israelsen S, Pedersen L, Bela Szecsi P, Benfield T. Higher levels of IL-1ra, IL-6, IL-8, MCP-1, MIP-3α, MIP-3β, and fractalkine are associated with 90-day mortality in 132 non-immunomodulated hospitalized patients with COVID-19. PLoS One 2024; 19:e0306854. [PMID: 38985797 PMCID: PMC11236197 DOI: 10.1371/journal.pone.0306854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/25/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Immune dysregulation with an excessive release of cytokines has been identified as a key driver in the development of severe COVID-19. The aim of this study was to evaluate the initial cytokine profile associated with 90-day mortality and respiratory failure in a cohort of patients hospitalized with COVID 19 that did not receive immunomodulatory therapy. METHODS Levels of 45 cytokines were measured in blood samples obtained at admission from patients with confirmed COVID-19. Logistic regression analysis was utilized to determine the association between cytokine levels and outcomes. The primary outcome was death within 90 days from admission and the secondary outcome was need for mechanical ventilation. RESULTS A total of 132 patients were included during the spring of 2020. We found that one anti-inflammatory cytokine, one pro-inflammatory cytokine, and five chemokines were associated with the odds of 90-day mortality, specifically: interleukin-1 receptor antagonist, interleukin-6, interleukin-8, monocyte chemoattractant protein-1, macrophage inflammatory protein-3α, macrophage inflammatory protein-3β, and fractalkine. All but fractalkine were also associated with the odds of respiratory failure during admission. Monocyte chemoattractant protein-1 showed the strongest estimate of association with both outcomes. CONCLUSION We showed that one anti-inflammatory cytokine, one pro-inflammatory cytokine, and five chemokines were associated with 90-day mortality in patients hospitalized with COVID-19 that did not receive immunomodulatory therapy.
Collapse
Affiliation(s)
- Liv Rabøl Andersen
- Center of Clinical Research and Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
| | - Bettina Hindsberger
- Center of Clinical Research and Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
| | - Simone Bastrup Israelsen
- Center of Clinical Research and Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
| | - Lise Pedersen
- Department of Clinical Biochemistry, Holbaek Hospital, Holbaek, Denmark
| | - Pal Bela Szecsi
- Center of Clinical Research and Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Biochemistry, Holbaek Hospital, Holbaek, Denmark
| | - Thomas Benfield
- Center of Clinical Research and Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
10
|
Jang JH, Choi E, Kim T, Yeo HJ, Jeon D, Kim YS, Cho WH. Navigating the Modern Landscape of Sepsis: Advances in Diagnosis and Treatment. Int J Mol Sci 2024; 25:7396. [PMID: 39000503 PMCID: PMC11242529 DOI: 10.3390/ijms25137396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024] Open
Abstract
Sepsis poses a significant threat to human health due to its high morbidity and mortality rates worldwide. Traditional diagnostic methods for identifying sepsis or its causative organisms are time-consuming and contribute to a high mortality rate. Biomarkers have been developed to overcome these limitations and are currently used for sepsis diagnosis, prognosis prediction, and treatment response assessment. Over the past few decades, more than 250 biomarkers have been identified, a few of which have been used in clinical decision-making. Consistent with the limitations of diagnosing sepsis, there is currently no specific treatment for sepsis. Currently, the general treatment for sepsis is conservative and includes timely antibiotic use and hemodynamic support. When planning sepsis-specific treatment, it is important to select the most suitable patient, considering the heterogeneous nature of sepsis. This comprehensive review summarizes current and evolving biomarkers and therapeutic approaches for sepsis.
Collapse
Affiliation(s)
- Jin Ho Jang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Eunjeong Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Taehwa Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Hye Ju Yeo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Doosoo Jeon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Woo Hyun Cho
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, Republic of Korea; (J.H.J.); (E.C.); (T.K.); (H.J.Y.); (D.J.); (Y.S.K.)
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| |
Collapse
|
11
|
Jansen A, Waalders N, Kox M, Pickkers P. Desorption in hemoadsorption therapies: a call for more data. Crit Care 2024; 28:207. [PMID: 38915114 PMCID: PMC11197250 DOI: 10.1186/s13054-024-04995-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/15/2024] [Indexed: 06/26/2024] Open
Affiliation(s)
- Aron Jansen
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500HB, Nijmegen, The Netherlands
| | - Nicole Waalders
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500HB, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500HB, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500HB, Nijmegen, The Netherlands.
| |
Collapse
|
12
|
Graf H, Gräfe C, Bruegel M, Zoller M, Maciuga N, Frank S, Weidhase L, Paal M, Scharf C. Myoglobin adsorption and saturation kinetics of the cytokine adsorber Cytosorb® in patients with severe rhabdomyolysis: a prospective trial. Ann Intensive Care 2024; 14:96. [PMID: 38907120 PMCID: PMC11192705 DOI: 10.1186/s13613-024-01334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Rhabdomyolysis is a serious condition that can lead to acute kidney injury with the need of renal replacement therapy (RRT). The cytokine adsorber Cytosorb® (CS) can be used for extracorporeal myoglobin elimination in patients with rhabdomyolysis. However, data on adsorption capacity and saturation kinetics are still missing. METHODS The prospective Cyto-SOLVE study (NCT04913298) included 20 intensive care unit patients with severe rhabdomyolysis (plasma myoglobin > 5000 ng/ml), RRT due to acute kidney injury and the use of CS for myoglobin elimination. Myoglobin and creatine kinase (CK) were measured in the patient´s blood and pre- and post-CS at defined time points (ten minutes, one, three, six, and twelve hours after initiation). We calculated Relative Change (RC, %) with: [Formula: see text]. Myoglobin plasma clearances (ml/min) were calculated with: [Formula: see text] RESULTS: There was a significant decrease of the myoglobin plasma concentration six hours after installation of CS (median (IQR) 56,894 ng/ml (11,544; 102,737 ng/ml) vs. 40,125 ng/ml (7879; 75,638 ng/ml) (p < 0.001). No significant change was observed after twelve hours. Significant extracorporeal adsorption of myoglobin can be seen at all time points (p < 0.05) (ten minutes, one, three, six, and twelve hours after initiation). The median (IQR) RC of myoglobin at the above-mentioned time points was - 79.2% (-85.1; -47.1%), -34.7% (-42.7;-18.4%), -16.1% (-22.1; -9.4%), -8.3% (-7.5; -1.3%), and - 3.9% (-3.9; -1.3%), respectively. The median myoglobin plasma clearance ten minutes after starting CS treatment was 64.0 ml/min (58.6; 73.5 ml/min), decreasing rapidly to 29.1 ml/min (26.5; 36.1 ml/min), 16.1 ml/min (11.9; 22.5 ml/min), 7.9 ml/min (5.5; 12.5 ml/min), and 3.7 ml/min (2.4; 6.4 ml/min) after one, three, six, and twelve hours, respectively. CONCLUSION The Cytosorb® adsorber effectively eliminates myoglobin. However, the adsorption capacity decreased rapidly after about three hours, resulting in reduced effectiveness. Early change of the adsorber in patients with severe rhabdomyolysis might increase the efficacy. The clinical benefit should be investigated in further clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT04913298. Registered 07 May 2021, https//clinicaltrials.gov/study/NCT04913298.
Collapse
Affiliation(s)
- Helen Graf
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Caroline Gräfe
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Mathias Bruegel
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nils Maciuga
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sandra Frank
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
13
|
Waalders N, van Lier D, Gerretsen J, Moran L, Stegmann KA, Twigger W, Blanco-Andujar C, Frodsham G, Kox M, Pickkers P. Preclinical and first-in-human safety studies on a novel magnetism-based haemofiltration method. Sci Rep 2024; 14:14077. [PMID: 38890397 PMCID: PMC11189386 DOI: 10.1038/s41598-024-64379-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Extracorporeal haemofiltration devices that selectively remove cytokines could represent an adjunctive treatment in inflammatory diseases. One such device is the "IL-6-Sieve", wherein magnetic Anti-IL-6 Beads are introduced into an extracorporeal circuit via a Bead Adapter and then removed along with any surface-bound interleukin (IL)-6 by a Filter deployed in a Magnet, before the blood is returned to the patient. We report here on a series of animal studies, and a first-in-human study, on the safety of the IL-6-Sieve. Evaluations focused on the: (a) safety of Filter and Magnet placed in an extracorporeal circuit in sheep; (b) safety of Anti-IL-6 Beads-directly infused intravenously as worst case scenario of misuse; or injected into an extracorporeal circuit using the Bead Adapter, Filter, and Magnet as intended-in sheep; (c) biodistribution of Anti-IL-6 Beads intravenously infused in mice; and (d) safety of Filter and Magnet placed in an extracorporeal circuit in healthy volunteers. No serious adverse events or significant changes in vital signs or routine laboratory parameters occurred in any of the animals or humans. Although safety of the IL-6-Sieve requires further study, these initial evaluations represent a promising start for the translation of this new blood purification modality into clinical use.
Collapse
Affiliation(s)
- Nicole Waalders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Dirk van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | | | | | | | | | | | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
- Radboud University Medical Center, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.
| |
Collapse
|
14
|
Papamichalis P, Oikonomou KG, Xanthoudaki M, Valsamaki A, Skoura AL, Papathanasiou SK, Chovas A. Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future. World J Crit Care Med 2024; 13:92458. [PMID: 38855267 PMCID: PMC11155504 DOI: 10.5492/wjccm.v13.i2.92458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 06/03/2024] Open
Abstract
Extracorporeal organ support (ECOS) has made remarkable progress over the last few years. Renal replacement therapy, introduced a few decades ago, was the first available application of ECOS. The subsequent evolution of ECOS enabled the enhanced support to many other organs, including the heart [veno-arterial extracorporeal membrane oxygenation (ECMO), slow continuous ultrafiltration], the lungs (veno-venous ECMO, extracorporeal carbon dioxide removal), and the liver (blood purification techniques for the detoxification of liver toxins). Moreover, additional indications of these methods, including the suppression of excessive inflammatory response occurring in severe disorders such as sepsis, coronavirus disease 2019, pancreatitis, and trauma (blood purification techniques for the removal of exotoxins, endotoxins, or cytokines), have arisen. Multiple organ support therapy is crucial since a vast majority of critically ill patients present not with a single but with multiple organ failure (MOF), whereas, traditional therapeutic approaches (mechanical ventilation for acute respiratory failure, antibiotics for sepsis, and inotropes for cardiac dysfunction) have reached the maximum efficacy and cannot be improved further. However, several issues remain to be clarified, such as the complexity and cost of ECOS systems, standardization of indications, therapeutic protocols and initiation time, choice of the patients who will benefit most from these interventions, while evidence from randomized controlled trials supporting their use is still limited. Nevertheless, these methods are currently a part of routine clinical practice in intensive care units. This editorial presents the past, present, and future considerations, as well as perspectives regarding these therapies. Our better understanding of these methods, the pathophysiology of MOF, the crosstalk between native organs resulting in MOF, and the crosstalk between native organs and artificial organ support systems when applied sequentially or simultaneously, will lead to the multiplication of their effects and the minimization of complications arising from their use.
Collapse
Affiliation(s)
| | | | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | | | | | - Achilleas Chovas
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| |
Collapse
|
15
|
Mariano F, Greco' D, Depetris N, Mella A, Sciarrillo A, Stella M, Berardino M, Risso D, Gambino R, Biancone L. CytoSorb® in burn patients with septic shock and Acute Kidney Injury on Continuous Kidney Replacement Therapy is associated with improved clinical outcome and survival. Burns 2024; 50:1213-1222. [PMID: 38494395 DOI: 10.1016/j.burns.2024.02.028] [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] [Received: 11/04/2023] [Revised: 02/01/2024] [Accepted: 02/27/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND In burn patients, septic shock and acute kidney injury (AKI) with use of continuous renal replacement therapy (CRRT) severely increase morbidity and mortality. Sorbent therapies could be an adjunctive therapy to address the underlying metabolic changes in inflammatory and anti-inflammatory cytokines dysregulated production. METHODS A retrospectively observational study of 35 severe burn patients admitted to the Burn Center (Turin, Italy, from January 2017 to December 2022), who underwent CRRT for AKI-associated septic shock. Out of 35 patients, 11 were treated with CytoSorb® as adjunctive therapy to CRRT (Sorbent group) and 24 patients only with CRRT (Control group). RESULTS The application of CytoSorb® took place in a very dispersed way. Out of 11 patients, 7 started the CRRT together with the sorbent application. The patients of the sorbent group exhibited a significant reduction in norepinephrine use compared to that of the control group. A clinical improvement over the first 4 days of Cytosorb® was observed in both survivors and no survivors of the sorbent group, with significant norepinephrine decreased use on day 4 compared to day 1. In-hospital mortality was 45.4% and 70.8% in the sorbent and control group, respectively, and significantly better at Kaplan-Meier survival analysis at 270 days (p = 0.0445). In both groups, all survivor patients recovered renal function at discharge, whereas no survivors did not. CONCLUSIONS Adjunctive treatment with CytoSorb® for burn patients with AKI-CRRT and septic shock poorly responsive to standard therapy led to a significant clinical improvement, and was associated with a lower mortality rate compared to CRRT alone.
Collapse
Affiliation(s)
- Filippo Mariano
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Domenico Greco'
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy
| | - Nadia Depetris
- Anesthesia and Intensive Care 3, Department of Anesthesia and Intensive Care, City of Health and Science, CTO Hospital, Turin, Italy
| | - Alberto Mella
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Sciarrillo
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Maurizio Stella
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Maurizio Berardino
- Anesthesia and Intensive Care 3, Department of Anesthesia and Intensive Care, City of Health and Science, CTO Hospital, Turin, Italy
| | - Daniela Risso
- Plastic Surgery and Burn Center, Department of General and Specialized Surgery, City of Health and Science, CTO Hospital, Turin, Italy
| | - Roberto Gambino
- Department of Medical Sciences, University of Turin, Turin, Italy; Laboratory of Diabetology and Metabolism, University of Turin, Italy
| | - Luigi Biancone
- Nephrology, Dialysis and Transplantation U, Department of General and Specialized Medicine, City of Health and Science, CTO Hospital, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| |
Collapse
|
16
|
Zhang Y, Chen C, Mitsnefes M, Huang B, Devarajan P. Evaluation of diagnostic accuracy of urine neutrophil gelatinase-associated lipocalin in patients with symptoms of urinary tract infections: a meta-analysis. Front Pediatr 2024; 12:1368583. [PMID: 38840804 PMCID: PMC11150804 DOI: 10.3389/fped.2024.1368583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/23/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Early and accurate diagnosis of urinary tract infection (UTI) can prevent serious sequelae including chronic kidney disease. Multiple individual studies have identified urine neutrophil gelatinase-associated lipocalin (uNGAL) as a promising biomarker for early diagnosis of UTI. We sought to understand the distribution and diagnostic accuracy of uNGAL values in patients presenting with UTI symptoms. Methods Our systematic literature reviews in PubMed, Embase, and Cochrane Reviews up to March 2024, identified 25 studies reporting mean/median, standard deviation/quartiles, and detection limits of uNGAL in symptomatic patients with and without culture-confirmed UTI. Seventeen studies were in children. Meta-analyses were performed using the quantile estimation (QE) method estimating the distributions of uNGAL, which were then compared between the UTI and non-UTI groups for identifying the best cut-off points maximizing the Youden index. Sensitivity analyses were performed on all 25 studies including adult patients. Results We found that uNGAL levels were significantly higher in samples with confirmed UTI compared to those without. In pediatric studies, median and 95% confidence interval (CI) of uNGAL values were 22.41 (95% CI of 9.94, 50.54) ng/mL in non-UTI group vs. 118.85 (95% CI of 43.07, 327.97) ng/mL in UTI group. We estimated the cut-off point of 48.43 ng/mL with highest sensitivity (96%) and specificity (97%) in children. Sensitivity analysis including both pediatric and adult studies yielded similar results. Discussion The level of uNGAL in symptomatic patients with confirmed UTI is much higher than that reported in patients without UTI. It may be used as a diagnostic tool to identify UTI early among symptomatic patients. The range of uNGAL concentrations and cut-off points reported in subjects with UTI is much lower than that reported in patients with acute intrinsic kidney injury. Systematic Review Registration https://www.crd.york.ac.uk/, PROSPERO (CRD42023370451).
Collapse
Affiliation(s)
- Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| |
Collapse
|
17
|
Gaspari R, Aceto P, Spinazzola G, Piervincenzi E, Chioffi M, Giuliante F, Antonelli M, Avolio AW. Blood Purification in Hepatic Dysfunction after Liver Transplant or Extensive Hepatectomy: Far from the Best-Case Scenarios. J Clin Med 2024; 13:2853. [PMID: 38792395 PMCID: PMC11122492 DOI: 10.3390/jcm13102853] [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: 03/19/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Hepatic dysfunction (HD) after liver transplantation (LT) or extended hepatic resection (EHR) is associated with graft failure and high short-term mortality. We evaluated the safety and depurative efficacy of CytoSorb® in these settings. The primary endpoint was the change in serum total bilirubin at the end of the treatment compared to the baseline value. The secondary endpoint was to evaluate the trend of serum total bilirubin and coagulation parameters up to 72 h after discontinuation of CytoSorb®. The effects of CytoSorb® therapy on the degree of hepatic encephalopathy (HE), Sequential Organ Failure Assessment (SOFA), and Model for End-Stage Liver Disease (MELD) scores as well as the hemodynamic status compared to baseline were also assessed. Methods: Adult patients with a serum total bilirubin level > 10 mg/dL admitted to the Intensive Care Unit were included. Exclusion criteria were hemodynamic instability, postoperative bleeding and platelet count < 20,000/mm3. Results: Seven patients were treated. Serum total bilirubin was significantly reduced at the end of treatment. However, seventy-two hours after the discontinuation of extracorporeal therapy, bilirubin levels returned to baseline levels in four patients. A decrease in platelet count was found during therapy, and platelet transfusion was required in six cases. A significant increase in D-dimer at the end of treatment was detected. HE degree, SOFA and MELD scores remained stable, while a deterioration in hemodynamic status was observed in two cases. Conclusions: Our preliminary findings did not show the possible benefits of CytoSorb® in rebalancing clinical and laboratory parameters in patients with HD after LT or EHR.
Collapse
Affiliation(s)
- Rita Gaspari
- Department of Basic Biotechnological Science, Intensive Care and Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Paola Aceto
- Department of Basic Biotechnological Science, Intensive Care and Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Edoardo Piervincenzi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Maurizio Chioffi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Felice Giuliante
- Department of Gastroenterological, Endocrine, Metabolic and Nephro-Urological Sciences, General Surgery and Hepatobiliary Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (F.G.); (A.W.A.)
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Basic Biotechnological Science, Intensive Care and Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.S.); (E.P.); (M.C.)
| | - Alfonso Wolfango Avolio
- Department of Gastroenterological, Endocrine, Metabolic and Nephro-Urological Sciences, General Surgery and Hepatobiliary Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (F.G.); (A.W.A.)
- Department of Gastroenterological, Endocrine, Metabolic and Nephro-Urological Sciences, General Surgery and Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| |
Collapse
|
18
|
Mehra MR, Castagna F. The Clinical Conundrum of Vasoplegia With Mechanical Circulatory Support Devices. JACC. ADVANCES 2024; 3:100914. [PMID: 38939633 PMCID: PMC11198417 DOI: 10.1016/j.jacadv.2024.100914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Mandeep R. Mehra
- Center for Advanced Heart Disease, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Francesco Castagna
- Center for Advanced Heart Disease, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Kasper R, Rodriguez-Alfonso A, Ständker L, Wiese S, Schneider EM. Major endothelial damage markers identified from hemadsorption filters derived from treated patients with septic shock - endoplasmic reticulum stress and bikunin may play a role. Front Immunol 2024; 15:1359097. [PMID: 38698864 PMCID: PMC11063272 DOI: 10.3389/fimmu.2024.1359097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction In septic patients the damage of the endothelial barrier is decisive leading to circulatory septic shock with disseminated vascular coagulation, edema and multiorgan failure. Hemadsorption therapy leads to rapid resolution of clinical symptoms. We propose that the isolation of proteins adsorbed to hemadsorption devices contributes to the identification of mediators responsible for endothelial barrier dysfunction. Material and methods Plasma materials enriched to hemadsorption filters (CytoSorb®) after therapy of patients in septic shock were fractionated and functionally characterized for their effect on cell integrity, viability, proliferation and ROS formation by human endothelial cells. Fractions were further studied for their contents of oxidized nucleic acids as well as peptides and proteins by mass spectrometry. Results Individual fractions exhibited a strong effect on endothelial cell viability, the endothelial layer morphology, and ROS formation. Fractions with high amounts of DNA and oxidized DNA correlated with ROS formation in the target endothelium. In addition, defined proteins such as defensins (HNP-1), SAA1, CXCL7, and the peptide bikunin were linked to the strongest additive effects in endothelial damage. Conclusion Our results indicate that hemadsorption is efficient to transiently remove strong endothelial damage mediators from the blood of patients with septic shock, which explains a rapid clinical improvement of inflammation and endothelial function. The current work indicates that a combination of stressors leads to the most detrimental effects. Oxidized ssDNA, likely derived from mitochondria, SAA1, the chemokine CXCL7 and the human neutrophil peptide alpha-defensin 1 (HNP-1) were unique for their significant negative effect on endothelial cell viability. However, the strongest damage effect occurred, when, bikunin - cleaved off from alpha-1-microglobulin was present in high relative amounts (>65%) of protein contents in the most active fraction. Thus, a relevant combination of stressors appears to be removed by hemadsorption therapy which results in fulminant and rapid, though only transient, clinical restitution.
Collapse
Affiliation(s)
- Robin Kasper
- Clinic of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Armando Rodriguez-Alfonso
- Core Facility Functional Peptidomics, Ulm University Medical Center, Ulm, Germany
- Core Unit Mass Spectrometry and Proteomics (CUMP), Ulm University, Ulm, Germany
| | - Ludger Ständker
- Core Facility Functional Peptidomics, Ulm University Medical Center, Ulm, Germany
| | - Sebastian Wiese
- Core Unit Mass Spectrometry and Proteomics (CUMP), Ulm University, Ulm, Germany
| | - E. Marion Schneider
- Clinic of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
20
|
Tegl V, Horak J, Nalos L, Horakova M, Stengl M, Matejovic M, Benes J. Ineffectiveness of hemoadsorption in large animals with abdominal sepsis: a randomized controlled porcine study. Intensive Care Med Exp 2024; 12:38. [PMID: 38635084 PMCID: PMC11026308 DOI: 10.1186/s40635-024-00622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES The use of hemoadsorption (HA) has become popular in the treatment of vasoplegic states associated with massive cytokine release, including septic shock. However, this approach does not seem to be based on robust evidence, and it does not follow international guidelines. To understand the pathophysiological rationale and timing of HA, we conducted a large animal septic shock experiment. DESIGN Prospective randomized large-animal peritoneal septic shock experiment. SETTING Laboratory investigation. SUBJECTS Twenty-six anesthetized, mechanically ventilated, and instrumented pigs randomly assigned into (1) sham-operated group with HA (SHAM, n = 5); (2) sepsis animals without HA (SEPSIS, n = 5); (3) sepsis group with HA at norepinephrine initiation (EARLY, n = 8); and (4) sepsis group with HA initiated at norepinephrine rate reaching 0.5 μg/kg/min (LATE, n = 8). INTERVENTIONS Peritoneal sepsis was induced by cultivated autologous feces inoculation. A CytoSorb cartridge (200 g) with a blood flow rate of 200 mL/min and heparin anticoagulation was used to perform HA. The animals received sedation and intensive organ support up to 48 h or until they experienced cardiovascular collapse. MEASUREMENTS AND MAIN RESULTS Systemic hemodynamics, multiple-organ functions, and immune-inflammatory response were measured at predefined periods. The HA treatment was not associated with any measurable benefit in terms of systemic hemodynamics and organ support. The systemic inflammatory markers were unaffected by any of the treatment timings. In contrast, the HA resulted in higher vasopressor load and decreased 36-h survival (5 animals in SHAM (100%), 4 (80%) in SEPSIS, 4 (57%) in EARLY, and 2 (25%) in LATE; p = 0.041). The HA exposure in healthy animals was associated with hemodynamic deterioration, systemic inflammatory response, and cytopenia. CONCLUSIONS In this large-animal-controlled fulminant sepsis study, the HA was unable to counteract the disease progression in the early or advanced septic shock phase. However, findings from the HA-exposed sham animals suggest potential safety concerns.
Collapse
Affiliation(s)
- Vaclav Tegl
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic
| | - Jan Horak
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Lukas Nalos
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Laboratory of Experimental Cardiology, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Michala Horakova
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic
| | - Milan Stengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Laboratory of Experimental Cardiology, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martin Matejovic
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jan Benes
- Laboratory of Experimental Intensive Care Medicine, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00, Pilsen, Czech Republic.
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
- Department of Anesthesiology, Resuscitation and Intensive Care, Faculty Hospital in Pilsen, Pilsen, Czech Republic.
| |
Collapse
|
21
|
Mehta Y, Singh A, Singh M, Bhan A, Trehan N. Impact of intraoperative haemoadsorption on outcomes of patients undergoing aortic surgery: a single-centre, prospective, observational study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae050. [PMID: 38514401 PMCID: PMC10984732 DOI: 10.1093/icvts/ivae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES To investigate the impact of a cytokine haemoadsorption (HA) device (CytoSorb®) on inflammatory markers and patients' outcome during aortic root surgery. METHODS Prospective, observational study including all-comers with quasi-randomization by strictly alternating inclusion (1:1 basis). Sixty patients undergoing elective aortic surgery were assigned to either HA group (n = 30) with intraoperative HA, or a control (C) group (n = 30). Primary outcomes were: (i) impact of HA on haemodynamic stability and need for vasopressors (vasoactive-inotropic score) and (ii) sequential organ failure assessment (SOFA) score. Secondary parameters included the impact of HA on the course of hyperinflammation using interleukin-6 and procalcitonin, duration of mechanical ventilation, and lengths of intensive care unit and hospital stay. RESULTS Noradrenaline requirement was significantly reduced in the HA group postoperatively compared to the C group (HA: 0.03 µg/kg/min vs C: 0.08 µg/kg/min, P = 0.004 at 2 h, and HA: 0.02 µg/kg/min vs C: 0.04 µg/kg/min, P = 0.004 at 24 h). This translated into a significantly lower vasoactive-inotropic score in the HA group. SOFA score was less in the HA group at all time points and reached statistical significance 2 h postoperatively (HA: 5.77 vs C: 7.43, P < 0.001). Intraoperative HA significantly reduced interleukin-6 levels (P < 0.05) at all time points, and procalcitonin at 2 h after discontinuation from cardiopulmonary bypass (P = 0.005). The duration of ventilation, intensive care unit and hospital stays were shorter in the HA group compared to the C group. CONCLUSIONS Intraoperative HA has the potential to mitigate hyperinflammatory response leading to improved haemodynamics after aortic root surgery, thereby shortening the duration of ventilation, and lengths of intensive care unit and hospital stay. However, it must be evaluated in larger cohorts.
Collapse
Affiliation(s)
- Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta—The Medicity, Gurugram, India
| | - Ajmer Singh
- Institute of Critical Care and Anesthesiology, Medanta—The Medicity, Gurugram, India
| | - Mandeep Singh
- Institute of Critical Care and Anesthesiology, Medanta—The Medicity, Gurugram, India
| | - Anil Bhan
- Department of Cardiac Surgery, Medanta—The Medicity, Gurugram, India
| | - Naresh Trehan
- Department of Cardiac Surgery, Medanta—The Medicity, Gurugram, India
| |
Collapse
|
22
|
Kooman JP. The Revival of Sorbents in Chronic Dialysis Treatment. Semin Dial 2024. [PMID: 38506130 DOI: 10.1111/sdi.13203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/04/2024] [Indexed: 03/21/2024]
Abstract
Interest in the use of sorbents in chronic dialysis treatment has undergone a revival in the last decades, for which two major factors are responsible. The first is the potential of sorbents as adjunct therapy for the removal of substances that are difficult to remove by conventional dialysis therapies. The second is their use in regeneration of dialysate, which is of pivotal importance in the design of portable or even wearable treatments, next to the potential for reducing water use during conventional dialysis treatment. Sorbent-enhanced dialysis with synthetic polymers was associated with a reduction in inflammatory parameters as compared to hemodialysis and even associated with improved survival in smaller studies, although this needs to be confirmed in large randomized trials. Incorporation of sorbents within a dialysis membrane (mixed matrix membrane) appears a promising way forward to reduce the complexity and costs of a dual therapy but needs to be tested in vivo. For regeneration of dialysate, at present, a combination of urease, zirconium-based sorbents, and activated charcoal is used. Next to sodium release by the sorbent in exchange for ammonium and the CO2 release by the hydrolysis of urea has been a bottleneck in the design of wearable devices, although short-term trials have been performed. Still, for widespread and flexible application of sorbent-assisted portable or wearable devices, a direct urea sorbent would be a major asset. In the near future, it will likely become apparent whether sorbent-assisted dialysis techniques are feasible for routine implementation in clinical practice.
Collapse
Affiliation(s)
- Jeroen Peter Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
23
|
Chen J, Yao G, Huang C, Shen Q, Miao J, Jia L. Biparatopic Nanobody-Based Immunosorbent for the Highly Selective Elimination of Tumor Necrosis Factor-α. ACS Biomater Sci Eng 2024; 10:1788-1795. [PMID: 38364210 DOI: 10.1021/acsbiomaterials.3c01765] [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: 02/18/2024]
Abstract
Removing the overexpressed TNF-α by hemoperfusion positively affects clinical treatments for diseases such as autoimmune disease and sepsis. However, clearance ratios of adsorbents targeting TNF-α were limited by the extremely low concentration of TNF-α (mostly <1000 ng/L in sepsis) and hydrophobic interactions. In this work, biparatopic nanobodies (NbC21) with a high affinity of 19.9 pM, which bind to two distinct sites of TNF-α, were constructed as high-affinity ligands for the immunosorbent. The theoretical maximum adsorption capacity estimated from the Langmuir isotherm was up to 18.22 mg/g gel. The prepared immunosorbent (NbC21-sorbent) had an outstanding TNF-α clearance ratio of approximately 96% during the dynamic adsorption test, with a sorbent-to-serum ratio of 1:1000. Additionally, it demonstrated favorable hemocompatibility and a prolonged storage capability. The results indicated that the biparatopic nanobody immunosorbent exhibited significant potential for clinical applications as it met the stringent criteria for both efficacy and safety.
Collapse
Affiliation(s)
- Jiewen Chen
- MOE Key Laboratory of Bio-Intelligent Manufacturing, Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116024, Liaoning, China
| | - Guangshuai Yao
- MOE Key Laboratory of Bio-Intelligent Manufacturing, Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116024, Liaoning, China
| | - Chundong Huang
- Kangyuan Biomedical Tech. (Dalian) Co., Ltd., Building 9, No. 57, Xinda Street, Dalian High-tech Zone, Dalian 116085, Liaoning, China
| | - Qidong Shen
- MOE Key Laboratory of Bio-Intelligent Manufacturing, Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116024, Liaoning, China
| | - Jian Miao
- The Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian 116027, Liaoning, China
| | - Lingyun Jia
- MOE Key Laboratory of Bio-Intelligent Manufacturing, Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116024, Liaoning, China
| |
Collapse
|
24
|
Amerson SJ, Hoffman M, Abouzahr F, Ahmad M, Sterling RK, Gidwani H, Sousse LE, Dellavolpe JD. Sequential Extracorporeal Therapy of Pathogen Removal Followed by Cell-Directed Extracorporeal Therapy in Streptococcal Toxic Shock Syndrome Refractory to Venoarterial Extracorporeal Membrane Oxygenation: A Case Report. Crit Care Explor 2024; 6:e1058. [PMID: 38415021 PMCID: PMC10898666 DOI: 10.1097/cce.0000000000001058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Streptococcal toxic shock syndrome (STSS) is a fulminant complication of predominantly invasive group A streptococcal infections. STSS is often characterized by influenza-like symptoms, including fever, chills, and myalgia that can quickly progress to sepsis with hypotension, tachycardia, tachypnea, and multiple organ failure (kidney, liver, lung, or blood). Mortality can exceed 50% depending on the severity of symptoms. CASE SUMMARY Here, we describe a novel, multi-extracorporeal intervention strategy in a case of severe septic shock secondary to STSS. A 28-year-old woman 5 days after cesarean section developed STSS with respiratory distress, hypotension, and multiple organ failure. Despite conventional therapy with intubation, antibiotics, vasopressors, and fluid resuscitation, her condition worsened. She was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with subsequent initiation of pathogen hemoperfusion using the Seraph 100 blood filter, followed by immunomodulation with the selective cytopheretic device (SCD). No device-related adverse events were observed. The patient's condition gradually stabilized with discontinuation of vasopressors after 4 days, ECMO decannulation after 6 days, evidence of renal recovery after 7 days, and extubation from mechanical ventilation after 14 days. She was transferred to conventional hemodialysis after 13 days and discontinued all kidney replacement therapy 11 days later. CONCLUSIONS This is the first reported use of VA-ECMO, Seraph 100 hemoperfusion, and cell-directed immunomodulation with SCD. This multimodal approach to extracorporeal support represents a promising therapeutic strategy for the most refractory critical care cases. Further studies are needed to assess the safety and efficacy of this sequential approach.
Collapse
Affiliation(s)
- Stephen J Amerson
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
| | - McKenna Hoffman
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
- Department of Internal Medicine, Methodist Healthcare System of San Antonio Ltd, San Antonio, TX
| | - Fadi Abouzahr
- Department of Internal Medicine, Division of Nephrology, Renal Associates PA, San Antonio, TX
| | - Mohammad Ahmad
- Department of Internal Medicine, Division of Nephrology, San Antonio Kidney Disease Center, San Antonio, TX
| | - Rachel K Sterling
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
| | - Hitesh Gidwani
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
| | - Linda E Sousse
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
| | - Jeffrey D Dellavolpe
- Department of Internal Medicine, The Institute for Extracorporeal Life Support and Texas Intensivist, Pulmonary, and Sleep Medicine, San Antonio, TX
| |
Collapse
|
25
|
Vogeler M, Schenz J, Müller E, Weigand M, Fischer D. [The Immune System of the Critically Ill Patient]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:96-112. [PMID: 38354730 DOI: 10.1055/a-2070-3516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Critically ill patients often experience a dysregulated immune response, leading to immune dysfunction. Sepsis, trauma, severe infections, and certain medical conditions can trigger a state of systemic inflammation, known as the cytokine storm. This hyperactive immune response can cause collateral damage to healthy tissues and organs, exacerbating the patient's condition. On the other hand, some critically ill patients may suffer from immune paralysis which can increase the risk of nosocomial infections.Fever is an evolutionary adaptation that evolved as an effective defense mechanism to fight invading pathogens. By raising body temperature, fever enhances the immune response, inhibits pathogen growth, promotes recovery, and aids in the formation of immune memory. Understanding the role of fever in the context of immune defense is crucial for optimizing medical interventions and supporting the body's natural ability to combat infections.Future Directions: Advancements in immunology research and technology hold promise for better understanding the immune system's complexities in critically ill patients. Personalized medicine approaches may be developed to tailor therapies to individual patients based on their immune profile, optimizing treatment outcomes. Based on recent studies prognostic parameters such as lymphocyte count, IL-10 concentration and mHLA-DR expression can be used to stratify the immunological response pattern in septic patients.Conclusion: The immune system's response in critically ill patients is a multifaceted process, involving intricate interactions between various immune cells, cytokines, and organs. Striking the delicate balance between immune activation and suppression remains a significant challenge in clinical practice. Continued research and therapeutic innovations are vital to improve patient outcomes and reduce the burden of critical illness on healthcare systems.
Collapse
|
26
|
Zikou X, Vaia D, Vasiliki P, Panagiotis C, Stavros A. Use of Therapeutic Apheresis methods in ICU. Transfus Apher Sci 2024; 63:103853. [PMID: 38049358 DOI: 10.1016/j.transci.2023.103853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Apheresis is a modern medical approach in which plasma or cellular components are separated from the whole blood. Apheresis can be either diagnostic or therapeutic. Diagnostic apheresis is typically applied in hematology and cancer research. Therapeutic Apheresis (TA) includes a broad spectrum of extracorporeal treatments applied in various medical specialties, including Intensive Care Unit (ICU). Considering the complexity of the pathophysiologic characteristics of various clinical entities and in particular sepsis, apheresis methods are becoming increasingly applicable. Therapeutic Plasma Exchange (TPE) is the most common used method in ICU. It is considered as first line therapy for Thrombotic Thrombocytopenic Purpura (TTP) and Guillain Barre Syndrome, while the current data for sepsis are scarce. Over the last decades, technologic evolution has led to increasing application of new and more selective methods based on adsorptive techniques. In this review we will describe the current data of characteristics of different techniques, safety and clinical impact of apheresis methods used in ICUs.
Collapse
|
27
|
Gong A, Li Y, Yang M, Wang S, Su B. A Contemporary Review of the Use of Extracorporeal CytoSorb ® Hemoadsorption Therapy in Patients with Infective Endocarditis. J Clin Med 2024; 13:763. [PMID: 38337456 PMCID: PMC10856698 DOI: 10.3390/jcm13030763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Infective endocarditis (IE) is a rare but severe disease with high morbidity and mortality. Cardiac surgery plays a major role in the contemporary clinical management of IE patients. During cardiac surgery, cardiopulmonary bypass significantly contributes to an increased risk of organ dysfunction and mortality by inducing an acute inflammatory response, vascular endothelial cell injury, impairment of the coagulation cascade, and ischemia-reperfusion injury. During the past decade, the use of extracorporeal hemoadsorption therapy with the CytoSorb® hemoadsorber (CytoSorbents Europe GmbH, Berlin, Germany) has been proposed as an adjuvant therapy to mediate inflammatory responses in IE patients undergoing cardiac surgery with cardiopulmonary bypass. However, there is currently no systematic evaluation of the effect of CytoSorb® hemoadsorption on clinical outcomes such as hemodynamics, organ dysfunction, and mortality in patients with IE. Therefore, in this review, we exclusively discuss contemporary findings concerning the rationale, clinical evidence, and future perspectives for CytoSorb® hemoadsorption therapy in IE patients.
Collapse
Affiliation(s)
- Anan Gong
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Yupei Li
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Mei Yang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China;
- Department of Nephrology, The First People’s Hospital of Shuangliu District, Chengdu 610200, China
| | - Shujing Wang
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Baihai Su
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
- Med+ Biomaterial Institute of West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, China
- Med-X Center for Materials, Sichuan University, Chengdu 610041, China
| |
Collapse
|
28
|
Stahl K, Bode C, Seeliger B, Wendel-Garcia PD, David S. Current clinical practice in using adjunctive extracorporeal blood purification in sepsis and septic shock: results from the ESICM "EXPLORATION" survey. Intensive Care Med Exp 2024; 12:5. [PMID: 38238627 PMCID: PMC10796869 DOI: 10.1186/s40635-023-00592-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/22/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Despite a lack of clear evidence extracorporeal blood purification (EBP) is increasingly used as an adjunctive treatment in septic shock based on its biological plausibility. However, current state of praxis and believes in both efficacy and level of evidence are very heterogeneous. METHODS The "EXPLORATION" (Current Clinical Practice in using adjunctive extracorporeal blood purification in septic shock), a web-based survey endorsed by the European Society of Intensive Care Medicine (ESICM), questioned both the current local clinical practices as well as future perspectives of EBP in sepsis and septic shock. RESULTS One hundred and two people participated in the survey. The majority of three quarters of participants (74.5%) use adjunctive EBP in their clinical routine with a varying frequency of description. Unselective cytokine adsorption (CA) (37.5%) and therapeutic plasma exchange (TPE) (34.1%) were by far the most commonly used modalities. While the overall theoretical rational was found to be moderate to high by the majority of the participants (74%), the effectively existing clinical evidence was acknowledged to be rather low (66%). Although CA was used most frequently in clinical practice, both the best existing clinical evidence endorsing its current use (45%) as well the highest potential to be explored in future clinical trials (51.5%) was attributed to TPE. CONCLUSIONS Although the majority of participants use EBP techniques in their clinical practice and acknowledge a subjective good theoretical rationale behind it, the clinical evidence is assessed to be limited. While both CA and TPE are by far the most common used technique, both clinical evidence as well as future potential for further exploration in clinical trials was assessed to be the highest for TPE.
Collapse
Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Carl-Neuberg Straße 1, 30163, Hannover, Germany.
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover Medical School (MHH), German Center for Lung Research (DZL), Hannover, Germany
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
29
|
Bellomo R, Mehta RL, Forni LG, Zarbock A, Ostermann M, Ronco C. Hemoadsorption. Clin J Am Soc Nephrol 2024; 19:01277230-990000000-00339. [PMID: 38214917 PMCID: PMC11168820 DOI: 10.2215/cjn.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/09/2024] [Indexed: 01/13/2024]
Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital; Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ravindra L. Mehta
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Lui G. Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guilford, United Kingdom
- Faculty of Health Sciences, University of Surrey, Guilford, United Kingdom
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital, Muenster, Germany
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Claudio Ronco
- Department of Medicine, University of Padua, Padua, Italy
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| |
Collapse
|
30
|
Li W, Chen Y, Li D, Meng X, Liu Z, Liu Y, Fan H. Hemoadsorption in acute respiratory distress syndrome patients requiring venovenous extracorporeal membrane oxygenation: a systematic review. Respir Res 2024; 25:27. [PMID: 38217010 PMCID: PMC10785465 DOI: 10.1186/s12931-024-02675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Venovenous extracorporeal membrane oxygenation (VV ECMO) has been widely used for severe acute respiratory distress syndrome (ARDS) in recent years. However, the role of hemoadsorption in ARDS patients requiring VV ECMO is unclear. METHODS Therefore, we conducted a systematic review to describe the effect of hemoadsorption on outcomes of ARDS patients requiring VV ECMO and elucidate the risk factors for adverse outcomes. We conducted and reported a systematic literature review based on the principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The systematic review searched Embase, CINHAL, and Pubmed databases for studies on ARDS patients receiving hemoadsorption and VV ECMO. The demographic data, clinical data and biological data of the patients were collected. RESULTS We ultimately included a total of 8 articles including 189 patients. We characterized the population both clinically and biologically. Our review showed most studies described reductions in inflammatory markers and fluid resuscitation drug dosage in ARDS patients with Coronavirus disease 2019 (COVID-19) or sepsis after hemoadsorption. CONCLUSION Because most of the studies have the characteristics of high heterogeneity, we could only draw very cautious conclusions that hemoadsorption therapy may enhance hemodynamic stability in ARDS patients with COVID-19 or sepsis receiving VV ECMO support. However, our results do not allow us to draw conclusions that hemoadsorption could reduce inflammation and mortality. Prospective randomized controlled studies with a larger sample size are needed in the future to verify the role of hemoadsorption in ARDS patients requiring VV ECMO.
Collapse
Affiliation(s)
- Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China.
| |
Collapse
|
31
|
Cicchinelli S, Pignataro G, Gemma S, Piccioni A, Picozzi D, Ojetti V, Franceschi F, Candelli M. PAMPs and DAMPs in Sepsis: A Review of Their Molecular Features and Potential Clinical Implications. Int J Mol Sci 2024; 25:962. [PMID: 38256033 PMCID: PMC10815927 DOI: 10.3390/ijms25020962] [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] [Received: 11/26/2023] [Revised: 12/31/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Sepsis is a serious organ dysfunction caused by a dysregulated immune host reaction to a pathogen. The innate immunity is programmed to react immediately to conserved molecules, released by the pathogens (PAMPs), and the host (DAMPs). We aimed to review the molecular mechanisms of the early phases of sepsis, focusing on PAMPs, DAMPs, and their related pathways, to identify potential biomarkers. We included studies published in English and searched on PubMed® and Cochrane®. After a detailed discussion on the actual knowledge of PAMPs/DAMPs, we analyzed their role in the different organs affected by sepsis, trying to elucidate the molecular basis of some of the most-used prognostic scores for sepsis. Furthermore, we described a chronological trend for the release of PAMPs/DAMPs that may be useful to identify different subsets of septic patients, who may benefit from targeted therapies. These findings are preliminary since these pathways seem to be strongly influenced by the peculiar characteristics of different pathogens and host features. Due to these reasons, while initial findings are promising, additional studies are necessary to clarify the potential involvement of these molecular patterns in the natural evolution of sepsis and to facilitate their transition into the clinical setting.
Collapse
Affiliation(s)
- Sara Cicchinelli
- Department of Emergency, S.S. Filippo e Nicola Hospital, 67051 Avezzano, Italy;
| | - Giulia Pignataro
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Stefania Gemma
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Andrea Piccioni
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Domitilla Picozzi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Veronica Ojetti
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli—IRRCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (G.P.); (S.G.); (A.P.); (D.P.); (V.O.); (F.F.)
| |
Collapse
|
32
|
Gül F, Ronco C. Current Trends in Hemoadsorption Treatment for Critically Ill Patients: are We Moving Forward? Balkan Med J 2024; 41:4-6. [PMID: 37702210 PMCID: PMC10767786 DOI: 10.4274/balkanmedj.galenos.2023.2023-14082023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Affiliation(s)
- Fethi Gül
- Department of Anesthesiology and Reanimation, Division of Critical Care, Marmara University Faculty of Medicine, İstanbul, Türkiye
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| |
Collapse
|
33
|
Bode C, Weis S, Sauer A, Wendel-Garcia P, David S. Targeting the host response in sepsis: current approaches and future evidence. Crit Care 2023; 27:478. [PMID: 38057824 PMCID: PMC10698949 DOI: 10.1186/s13054-023-04762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
Sepsis, a dysregulated host response to infection characterized by organ failure, is one of the leading causes of death worldwide. Disbalances of the immune response play an important role in its pathophysiology. Patients may develop simultaneously or concomitantly states of systemic or local hyperinflammation and immunosuppression. Although a variety of effective immunomodulatory treatments are generally available, attempts to inhibit or stimulate the immune system in sepsis have failed so far to improve patients' outcome. The underlying reason is likely multifaceted including failure to identify responders to a specific immune intervention and the complex pathophysiology of organ dysfunction that is not exclusively caused by immunopathology but also includes dysfunction of the coagulation system, parenchymal organs, and the endothelium. Increasing evidence suggests that stratification of the heterogeneous population of septic patients with consideration of their host response might led to treatments that are more effective. The purpose of this review is to provide an overview of current studies aimed at optimizing the many facets of host response and to discuss future perspectives for precision medicine approaches in sepsis.
Collapse
Affiliation(s)
- Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute-HKI, Jena, Germany
| | - Andrea Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Pedro Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Gräfe C, Weidhase L, Liebchen U, Weigand MA, Scharf C. [Hemoperfusion in anesthesia and intensive care medicine: benefits, risks, and evidence for different systems]. DIE ANAESTHESIOLOGIE 2023; 72:843-851. [PMID: 37707564 DOI: 10.1007/s00101-023-01341-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies. OBJECTIVE The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany. METHOD To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies. RESULTS In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis. DISCUSSION Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given.
Collapse
Affiliation(s)
- Caroline Gräfe
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Lorenz Weidhase
- Interdisziplinäre internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christina Scharf
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
| |
Collapse
|
36
|
Supady A. [Cytokine adsorption in extracorporeal membrane oxygenation]. Med Klin Intensivmed Notfmed 2023; 118:499-501. [PMID: 37532792 DOI: 10.1007/s00063-023-01058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Alexander Supady
- Interdisziplinäre Internistische Intensivmedizin (IMIT), Uniklinik Freiburg, Medizinische Fakultät, Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| |
Collapse
|
37
|
Jerman A, Gubenšek J, Berden J, Peršič V. A matched case-control study on the effectiveness of extracorporeal cytokine adsorption in critically ill patients. Sci Rep 2023; 13:13464. [PMID: 37596304 PMCID: PMC10439174 DOI: 10.1038/s41598-023-40719-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/16/2023] [Indexed: 08/20/2023] Open
Abstract
Extracorporeal cytokine adsorption aims to reduce cytokine levels in critically ill patients. However, little convincing data exist to support its widespread use. This retrospective study compared interleukin-6 (IL-6) levels in patients treated with or without cytokine adsorber (CytoSorb®). Intensive care patients between Jan 2017 and Dec 2021 who had at least two IL-6 measurements were included. They were divided into an adsorber group and a standard of care group. We screened 3865 patients and included 52 patients in the adsorber group and 94 patients in the standard of care group. Matching was performed and the groups were compared regarding IL-6, lactate, CRP, procalcitonin, vasopressor requirement, and mortality rate. After matching, there were 21 patients in each group. Patients had similar age, ECMO and renal replacement therapy use, baseline noradrenaline requirement, serum lactate, pH, CRP, and IL-6 levels. There were no significant differences in the time course of IL-6, lactate, CRP, procalcitonin and noradrenaline requirement between groups. Two-day and ICU mortality and Kaplan-Meier estimated survival were also comparable. In this matched case-control study no difference in IL-6, inflammatory parameters, noradrenaline requirement or mortality was observed between patients treated with adsorber or standard of care.
Collapse
Affiliation(s)
- Alexander Jerman
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia.
| | - Jakob Gubenšek
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jernej Berden
- Department for Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Vanja Peršič
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
38
|
Haertel F, Lehmann T, Heller T, Fritzenwanger M, Pfeifer R, Kretzschmar D, Otto S, Bogoviku J, Westphal J, Bruening C, Gecks T, Kaluza M, Moebius-Winkler S, Schulze PC. Impact of a VA-ECMO in Combination with an Extracorporeal Cytokine Hemadsorption System in Critically Ill Patients with Cardiogenic Shock-Design and Rationale of the ECMOsorb Trial. J Clin Med 2023; 12:4893. [PMID: 37568295 PMCID: PMC10420280 DOI: 10.3390/jcm12154893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Cardiogenic shock and arrest present as critical, life-threatening emergencies characterized by severely compromised tissue perfusion and inadequate oxygen supply. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) serves as a mechanical support system for patients suffering shock refractory to conventional resuscitation. Despite the utilization of VA-ECMO, clinical deterioration due to systemic inflammatory response syndrome (SIRS) resulting from the underlying shock and exposure of blood cells to the artificial surfaces of the ECMO circuit may occur. To address this issue, cytokine adsorbers offer a valuable solution by eliminating blood proteins, thereby controlling SIRS and potentially improving hemodynamics. Consequently, a prospective, randomized, blinded clinical trial will be carried out with ECMOsorb. METHODS AND STUDY DESIGN ECMOsorb is a single-center, controlled, randomized, triple-blinded trial that will compare the hemodynamic effects of treatment with a VA-ECMO in combination with a cytokine adsorber (CytoSorb®, intervention) to treatment with VA-ECMO only (control) in patients with cardiogenic shock (with or without prior cardiopulmonary resuscitation (CPR)) requiring extracorporeal, hemodynamic support. Fifty-four patients will be randomized in a 1:1 fashion to the intervention or control group over a 36-month period. The primary endpoint of ECMOsorb is the improvement of the Inotropic Score (IS) 72 h after the intervention. Prognostic indicators, including mortality rates, hemodynamic parameters, laboratory findings, echocardiographic assessments, quality of life measurements, and clinical parameters, will serve as secondary outcome measures. The safety evaluation encompasses endpoints such as air embolisms, allergic reactions, peripheral ischemic complications, vascular complications, bleeding incidents, and stroke occurrences. CONCLUSIONS The ECMOsorb trial seeks to assess the efficacy of a cytokine adsorber (CytoSorb®; CytoSorbents Europe GmbH, Berlin, Germany) in reducing SIRS and improving hemodynamics in patients with cardiogenic shock who are receiving VA-ECMO. We hypothesize that a reduction in cytokine levels can lead to faster weaning from inotropic and mechanical circulatory support, and ultimately to improved recovery.
Collapse
Affiliation(s)
- Franz Haertel
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Lehmann
- Center of Clinical Studies, University Hospital Jena, Salvador-Allende-Platz 27, 07747 Jena, Germany
| | - Tabitha Heller
- Center of Clinical Studies, University Hospital Jena, Salvador-Allende-Platz 27, 07747 Jena, Germany
| | - Michael Fritzenwanger
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ruediger Pfeifer
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sylvia Otto
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Jurgen Bogoviku
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Julian Westphal
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Christiane Bruening
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Thomas Gecks
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Mirko Kaluza
- Department of Cardiothoracic Surgery, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sven Moebius-Winkler
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - P. Christian Schulze
- Department of Cardiology and Intensive Care, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| |
Collapse
|
39
|
Supady A, Staudacher DL, Wengenmayer T. Comment on: Extracorporeal hemoadsorption in critically ill COVID‑19 patients on VV ECMO: the CytoSorb therapy in COVID‑19 (CTC) registry. Crit Care 2023; 27:297. [PMID: 37488613 PMCID: PMC10367240 DOI: 10.1186/s13054-023-04578-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- A Supady
- Interdisciplinary Medical Intensive Care, Medical Center, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
| | - D L Staudacher
- Interdisciplinary Medical Intensive Care, Medical Center, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - T Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|