Role of Hemoperfusion With CytoSorb Associated With Continuous Kidney Replacement Therapy on Renal Outcome in Critically III Children With Septic Shock

Hemoadsorption: consensus report of the 30th Acute Disease Quality Initiative workgroup

Adsorption-based extracorporeal therapies have been subject to technical developments and clinical application for close to five decades. More recently, new technological developments in membrane and sorbent manipulation have made it possible to deliver more biocompatible extracorporeal adsorption therapies to patients with a variety of conditions. There are several key rationales based on physicochemical principles and clinical considerations that justify the application and investigation of such therapies as evidenced by multiple ex vivo, experimental and clinical observations. Accordingly, unspecific adsorptive extracorporeal therapies have now been applied to the treatment of a wide array of conditions from poisoning to drug overdoses, to inflammatory states and sepsis, and acute or chronic liver and kidney failure. In response to the rapidly expanding knowledge base and increased clinical evidence, we convened an Acute Disease Quality Initiative consensus conference dedicated to such treatment. The data show that hemoadsorption has clinically acceptable short-term biocompatibility and safety, technical feasibility and experimental demonstration of specified target molecule removal. Pilot studies demonstrate potentially beneficial effects on physiology and larger studies of endotoxin-based hemoadsorption have identified possible target phenotypes for larger randomized controlled trials. Moreover, in a variety of endogenous and exogenous intoxications, removal of target molecules has been confirmed in vivo. However, some studies have raised concerns about harm, or failed to deliver benefits. Thus, despite many achievements, modern hemoadsorption remains a novel and experimental intervention with limited data, and a large research agenda.

Hemoadsorption improves kidney microcirculatory oxygenation and oxygen consumption, ameliorates tubular injury, and improves kidney function in a rat model of sepsis-induced AKI

Microcirculatory dysfunction, hypoxia, and inflammation are considered to be central in the pathogenesis of sepsis-induced acute kidney injury (AKI). In this experimental study, we hypothesized that extracorporeal removal of inflammatory cytokines by hemoadsorption (HA) therapy may mitigate renal injury associated with sepsis-induced AKI. To this end, we investigated renal microcirculatory oxygenation and perfusion, oxygen consumption, lactate, systemic hemodynamic variables, tubular cell integrity, inflammatory mediators, and kidney function in a rat model of septic AKI elicited by endotoxin infusion. Three groups of rats were investigated on extracorporeal circulation: HA only, LPS, and LPS + HA. Endotoxin infusion reduced cortex microcirculatory oxygenation and raised creatinine and lactate levels. Renal microcirculatory oxygenation, measured by two independent techniques (phosphorescence (µPO2) and spectrophotometry/Doppler (µHbO2sat and [Formula: see text])), was ameliorated by HA therapy. The renal oxygen consumption, lactate and creatinine levels were restored in the LPS + HA group. A reduced amount of injured tubular cells was found in histological analysis of the kidneys. This experimental study demonstrated an improvement in multiple determinants of kidney oxygenation, damage, and systemic blood perfusion by HA in a clinically relevant rat model of septic AKI. Further studies are needed to optimize and support the clinical use of HA as a renal protective strategy.

Hemadsorption with CytoSorb in Infants with Sepsis: Non-Systematic Review of Cases

Sepsis is a severe and potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs. It can lead to organ failure and death if not treated. Cytosorb is a promising medical device for hemadsorption in pediatric septic patients (under 18 years old). As many studies conclude, Cytosorb results in efficient hemodynamics stabilization. This paper is a nonsystematic review of cases. PubMed-, Google Scholar-, and Scopus-indexed journals were used to collect papers for the research. Overall, 11 pediatric cases (six journal articles) were collected. Reductions in interleukin (IL)-6 and IL-10 levels after hemoperfusion with CytoSorb suggest a potential benefit in modulating the inflammatory response in pediatric patients. Moreover, other septic shock indicators such as C-reactive protein, lactate, procalcitonin, ALT, and AST were also significantly reduced in surviving patients within the first few hours of hemadsorption with CytoSorb. The use of CytoSorb seems to be efficient in managing different sepsis-related conditions, even in neonatal and infant populations, as a valuable supplementary tool. However, overcoming the obstacles associated with the age and weight of pediatric patients might necessitate the creation of CytoSorb devices tailored specifically to their needs.

CVVHDF combined with cytokine adsorption column ameliorates severe catheter-related bloodstream infection in a hemodialysis patient

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.

Outcomes of CAR-T Cell Therapy Recipients Admitted to the ICU: In Search for a Standard of Care-A Brief Overview and Meta-Analysis of Proportions

OBJECTIVE

Our primary objective was to describe the baseline characteristics, main reasons for intensive care unit (ICU) admission, and interventions required in the ICU across patients who received CAR-T cell immunotherapy. The secondary objectives were to evaluate different outcomes (ICU mortality) across patients admitted to the ICU after having received CAR-T cell therapy.

MATERIALS AND METHODS

We performed a medical literature review, which included MEDLINE, Embase, and Cochrane Library, of studies published from the inception of the databases until 2022. We conducted a systematic review with meta-analyses of proportions of several studies, including CAR-T cell-treated patients who required ICU admission. Outcomes in the meta-analysis were evaluated using the random-effects model.

RESULTS

We included four studies and analyzed several outcomes, including baseline characteristics and ICU-related findings. CAR-T cell recipients admitted to the ICU are predominantly males (62% CI-95% (57-66)). Of the total CAR-T cell recipients, 4% CI-95% (3-5) die in the hospital, and 6% CI-95% (4-9) of those admitted to the ICU subsequently die. One of the main reasons for ICU admission is acute kidney injury (AKI) in 15% CI-95% (10-19) of cases and acute respiratory failure in 10% CI-95% (6-13) of cases. Regarding the interventions initiated in the ICU, 18% CI-95% (13-22) of the CAR-T recipients required invasive mechanical ventilation during their ICU stay, 23% CI-95% (16-30) required infusion of vasoactive drugs, and 1% CI-95% (0.1-3) required renal replacement therapy (RRT). 18% CI-95% (13-22) of the initially discharged patients were readmitted to the ICU within 30 days, and the mean length of hospital stay is 22 days CI-95% (19-25). The results paint a current state of matter in CAR-T cell recipients admitted to the ICU.

CONCLUSIONS

To better understand immunotherapy-related complications from an ICU standpoint, acknowledge the deteriorating patient on the ward, reduce the ICU admission rate, advance ICU care, and improve the outcomes of these patients, a standard of care and research regarding CAR-T cell-based immunotherapies should be created. Studies that are looking from the perspective of intensive care are highly warranted because the available literature regarding this area is scarce.

Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study

Background

There is a lack of data to support the use of hemoadsorption in pediatric septic shock. The aim of our study was to assess the effectiveness and safety of CytoSorb therapy in this setting.

Methods

Phase II interventional single arm pilot study in which 17 consecutive children admitted with septic shock who required continuous kidney replacement therapy (CKRT) and weighed ≥10 kg were included. A CytoSorb (CytoSorbents Inc, New Jersey, USA) hemoadsorption cartridge was added to the CKRT every 24 h for a maximum of 96 h. A control group of 13 children with septic shock treated with CKRT but not hemoadsorption at Children's Hospital Bambino Gesù and enrolled in the EuroAKId register was selected as an historical cohort. The primary outcome of the study was a reduction in vasopressor or inotrope dose of >50% from baseline by the end of CytoSorb therapy. Secondary outcomes included hemodynamic and biological changes, changes in severity scores, and 28-day mortality.

Results

There were significant decreases in the Vasoactive Inotropic Score (VIS) and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score at 72 and 96 h from the start of the CytoSorb therapy compared to baseline; the reductions were larger in the hemoadsorption group than in the control group (historical cohort). 28-day mortality was lower, although not significantly, in the hemoadsorption group when compared to the control group (5/17 [29%] vs. 8/13 [61%] OR 0.26 [95% CI: 0.05-1.2]; p = 0.08).

Conclusions

CytoSorb therapy may have some benefits in pediatric patients with septic shock. Future larger randomized trials are needed in this setting.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05658588, identifier (Clinicaltrials.gov NCT05658588).

Comprehensive analysis of ceRNA network composed of circRNA, miRNA, and mRNA in septic acute kidney injury patients based on RNA-seq

Background: Sepsis is a complex, life-threatening clinical syndrome that can cause other related diseases, such as acute kidney injury (AKI). Circular RNA (circRNA) is a type of non-coding RNA with a diverse range of functions, and it plays essential roles in miRNA sponge. CircRNA plays a huge part in the development of various diseases. CircRNA and the competing endogenous RNA (ceRNA) regulatory network are unknown factors in the onset and progression of septic AKI (SAKI). This study aimed to clarify the complex circRNA-associated regulatory mechanism of circRNAs in SAKI. Methods: We collected 40 samples of whole blood of adults, including 20 cases of SAKI and 20 cases of healthy controls. Moreover, five cases were each analyzed by RNA sequencing, and we identified differentially expressed circRNA, miRNA, and mRNA (DEcircRNAs, DEmiRNAs, and DEmRNAs, respectively). All samples were from SAKI patients with intraperitoneal infection. Results: As a result, we screened out 236 DEcircRNAs, 105 DEmiRNAs, and 4065 DEmRNAs. Then, we constructed two co-expression networks based on RNA-RNA interaction, including circRNA-miRNA and miRNA-mRNA co-expression networks. We finally created a circRNA-miRNA-mRNA regulation network by combining the two co-expression networks. Functional and pathway analyses indicated that DEmRNAs in ceRNA were mostly concentrated in T cell activation, neutrophils and their responses, and cytokines. The protein-protein interaction network was established to screen out the key genes participating in the regulatory network of SAKI. The hub genes identified as the top 10 nodes included the following: ZNF727, MDFIC, IFITM2, FOXD4L6, CIITA, KCNE1B, BAGE2, PPIAL4A, USP17L7, and PRSS2. Conclusion: To our knowledge, this research is the first study to describe changes in the expression profiles of circRNAs, miRNAs, and mRNAs in patients with SAKI. These findings provide a new treatment target for SAKI treatment and novel ideas for its pathogenesis.

Impact of Continuous Kidney Replacement Therapy and Hemoadsorption with CytoSorb on Antimicrobial Drug Removal in Critically Ill Children with Septic Shock: A Single-Center Prospective Study on a Pediatric Cohort

Background: Extracorporeal therapies (ET) are increasingly used in pediatric settings as adjuvant therapeutic strategies for overwhelming inflammatory conditions. Although these treatments seem to be effective for removing inflammatory mediators, their influence on antimicrobials pharmacokinetic should not be neglected. Methods: A prospective observational study of children admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis/septic shock. All critically ill children received hemoadsorption treatment with CytoSorb (CS) in combination with CKRT. Therapeutic drug monitoring has been performed on 10 critically ill children, testing four antimicrobial molecules: meropenem, ceftazidime, amikacin and levofloxacin. In order to evaluate the total and isolated CKRT and CS contributions to antibiotic removal, blood samples at each circuit point (post-hemofilter, post-CS and in the effluent line) were performed. Therefore, the clearance and mass Removal (MR) of the hemofilter and CS were calculated. Results: Our preliminary report describes a different impact of CS on these target drugs removal: CS clearance was low for amikacine (6-12%), moderate for ceftazidime (43%) and moderate to high for levofloxacine (52-72%). Higher MR and clearance were observed with CKRT compared to CS. To the best of our knowledge, this is the first report regarding pharmacokinetic dynamics in critically ill children treated with CKRT and CS for septic shock.

Efficacy of CytoSorb®: a systematic review and meta-analysis

INTRODUCTION

Cytokine adsorption using the CytoSorb® adsorber has been proposed in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or recovery after cardiac arrest. The aim of this analysis is to provide evidence for the efficacy of the CytoSorb® adsorber with regard to mortality in various settings.

METHODS

We searched PubMed, Cochrane Library database and the database provided by Cytosorbents™ (01.1.2010-29.5.2022). We considered randomized controlled trials and observational studies with control groups. The longest reported mortality was defined as the primary endpoint. We computed risk ratios and 95%-confidence intervals and used DerSimonian and Lairds random effects model. We analysed all studies combined and divided them into the subgroups: sepsis, cardiopulmonary bypass surgery (CPB), other severe illness, SARS-CoV-2 infection and recovery from cardiac arrest. The meta-analysis was registered in advance (PROSPERO: CRD42022290334).

RESULTS

Of an initial 1295 publications, 34 studies were found eligible, including 1297 patients treated with CytoSorb® and 1314 controls. Cytosorb® intervention did not lower mortality (RR [95%-CI]: all studies 1.07 [0.88; 1.31], sepsis 0.98 [0.74; 1.31], CPB surgery 0.91 [0.64; 1.29], severe illness 0.95 [0.59; 1.55], SARS-CoV-2 1.58 [0.50; 4.94]). In patients with cardiac arrest, we found a significant survival advantage of the untreated controls (1.22 [1.02; 1.46]). We did not find significant differences in ICU length of stay, lactate levels, or IL-6 levels after treatment. Of the eligible 34 studies only 12 were randomized controlled trials. All observational studies showed moderate to serious risk of bias.

INTERPRETATION

To date, there is no evidence for a positive effect of the CytoSorb® adsorber on mortality across a variety of diagnoses that justifies its widespread use in intensive care medicine.

Clinical effects of continuous veno-venous hemofiltration combined with hemoperfusion for the treatment of multiple myeloma complicated with acute kidney injury

Objective

To evaluate the clinical efficacy of continuous veno-venous hemofiltration (CVVH) combined with hemoperfusion for the treatment of multiple myeloma (MM) complicated with acute kidney injury (AKI).

Methods

Medical records of 73 patients with MM complicated with AKI admitted to the First People's Hospital of Huzhou from January 2019 to January 2021 were retrospectively analyzed. According to the treatment records, 35 patients received simple chemotherapy (control group), and 38 patients received CVVH combined with HP on the basis of chemotherapy (observation group). We compared the clinical efficacies, renal function indexes, and the serum globulin and erythrocyte sedimentation rate (ESR) values between the two groups.

Results

After the treatment, the total efficacy of the observation group was significantly higher (81.58%) than that in the control group (57.14%; p <0.05). Serum cystatin C (CysC), urea nitrogen (BUN), β2 macroglobulin (β2-MG) and creatinine (SCr) levels were significantly lower in the observation group than in the control group (p <0.05). Serum globulin level and ESR values in the observation group after the treatment were also significantly lower than in the control group (p <0.05).

Conclusions

The outcomes of patients with MM complicated with AKI treated with CVVH and hemoperfusion differ significantly from those of the patients treated only with CVVH. Combining CVVH and hemoperfusion helps to improve the efficacy of the treatment, promotes renal function recovery, and improves the levels of serum globulin and ESR.

Hemoperfusion in the intensive care unit

Multiple organ failure following a septic event derives from immune dysregulation. Many of the mediators of this process are humoral factors (cytokines), which could theoretically be cleared by direct adsorption through a process called hemoperfusion. Hemoperfusion through devices, which bind specific molecules like endotoxin or theoretically provide non-specific adsorption of pro-inflammatory mediators has been attempted and studied for several decades with variable results. More recently, technological evolution has led to the increasing application of adsorption due to more biocompatible and possibly more efficient biomaterials. As a result, new indications are developing in this field, and novel tools are available for clinical use. This narrative review will describe current knowledge regarding technical concepts, safety, and clinical results of hemoperfusion. Finally, it will focus on the most recent literature regarding adsorption applied in critically ill patients and their indications, including recent randomized controlled trials and future areas of investigation. Clinical trials for the assessment of efficacy of hemoperfusion in septic patients should apply the explanatory approach. This includes a highly selected homogenous patient population. Enrichment criteria such as applying genetic signature and molecular biomarkers allows the identification of subphenotypes of patients. The intervention must be delivered by a multidisciplinary team of trained personnel. The aim is to maximize the signals for efficacy and safety. In a homogenous cohort, confounding uncontrolled variables are less likely to exist. Trials with highly selected populations have a high internal validity but poor generalizability. The parallel design described in the figure is robust and usually is required by regulatory agencies for the approval of a new treatment. Allocation concealment and randomization are key to minimize bias such as confirmation bias, observer bias. The intervention should be delivered following a strict protocol. Deviations from the protocol might negatively influence the potential effects of the therapies. Surrogates such as cytokine measurement are adequate primary outcomes in phase 3 trials with small sample size because there is a higher likelihood of finding positive results concerning surrogate markers than in respect with clinical outcomes. Once a trial shows positive results concerning surrogate markers, a rationale for another phase 3 trial exploring clinical outcomes is built, justifying the allocation of financial sources to the intended trial.

Effects of the timing and intensity of treatment on septic shock patients treated with CytoSorb®: Clinical experience

INTRODUCTION

A group of adult septic shock patients treated with hemoperfusion (HA) with the Cytosorb^® associated with CVVHD were studied to determine (a) the effects of this technique on different clinical variables; and (b) the impact of the pre CytoSorb^® interval and its intensity on the outcome.

METHODS

The catecholamine index (CI) and the pressure-catecholamine Index (PCAI) were used to assess the amount of catecholamine administered at baseline and during the procedure, respectively. The pre-treatment time was calculated since the onset of the septic-shock related hypotension and the initiation of the first session and the intensity was assessed considering either the total volume of blood processed and the duration of the HA.

RESULTS

Overall, 51 patients with septic shock (30 m, 21 f), age 68 years (IQR 59-76) were retrospectively enrolled in the study; 26 were discharged alive form the ICU (S) and 25 died in ICU (NS); in the S group either CI and PCAI decreased significantly but in NS the CI increased and the PCAI remained stable in NS. In S, the time elapsing from the onset of symptoms and the start of Cytosorb^® was shorter than in NS; the duration of the treatment and the volume of blood processed were significantly higher in S than in NS.

CONCLUSIONS

In this group of septic shock patients, the earlier initiation of Cytosorb^®, its longer duration and the higher volume of blood processed were associated with a better survival.