Extracorporeal therapies in sepsis

The treatment of sepsis is an ongoing challenge for clinicians; despite the wide choice of effective antibiotics to treat infection, sepsis remains the leading cause of morbidity and mortality for patients admitted to an intensive care unit. Dysregulation of the immune response is now recognized to be a key factor in multiple organ dysfunction, yet our therapy for inflammation remains ineffective. It has been advocated for more than a decade that cytokine reduction in blood compartment could lead to a reduction in mortality in sepsis. Over the years, multiple extracorporeal techniques have evolved, with the intent of influencing the circulating levels of inflammatory mediators like cytokines and chemokines, the complement system, as well as factors of the coagulation system. These include high-volume hemofiltration, use of high cutoff membranes, and systems based on adsorption, such as coupled plasma filtration adsorption and the polymyxin-B column. In addition, new experimental systems that utilize human phagocytic cells and immobilized antibodies for targeted immunomodulation have emerged. In the context of limited resources and growing expansion in the availability of technologies, a better understanding of these therapies is required before they can be properly integrated into standard clinical practice in the hope of influencing major clinical outcomes. In this article, we will provide a concise overview of selected extracorporeal modalities currently in clinical use and briefly introduce some new promising techniques for sepsis.

Treatment of Cytokine Storm in COVID-19 Patients With Immunomodulatory Therapy

Observational evidence suggests that excessive inflammation with cytokine storm may play a critical role in development of acute respiratory distress syndrome (ARDS) in COVID-19. We report the emergency use of immunomodulatory therapy utilizing an extracorporeal selective cytopheretic device (SCD) in two patients with elevated serum interleukin (IL)-6 levels and refractory COVID-19 ARDS requiring extracorporeal membrane oxygenation (ECMO). The two patients were selected based on clinical criteria and elevated levels of IL-6 (>100 pg/ml) as a biomarker of inflammation. Once identified, emergency/expanded use permission for SCD treatment was obtained and patient consented. Six COVID-19 patients (four on ECMO) with severe ARDS were also screened with IL-6 levels less than 100 pg/ml and were not treated with SCD. The two enrolled patients' PaO2/FiO2 ratios increased from 55 and 58 to 200 and 192 at 52 and 50 hours, respectively. Inflammatory indices also declined with IL-6 falling from 231 and 598 pg/ml to 3.32 and 116 pg/ml, respectively. IL-6/IL-10 ratios also decreased from 11.8 and 18 to 0.7 and 0.62, respectively. The two patients were successfully weaned off ECMO after 17 and 16 days of SCD therapy, respectively. The results observed with SCD therapy on these two critically ill COVID-19 patients with severe ARDS and elevated IL-6 is encouraging. A multicenter clinical trial is underway with an FDA-approved investigational device exemption to evaluate the potential of SCD therapy to effectively treat COVID-19 intensive care unit patients.

Kidney Replacement Therapy in COVID-19 Induced Kidney Failure and Septic Shock: A Pediatric Continuous Renal Replacement Therapy [PCRRT] Position on Emergency Preparedness With Resource Allocation

The recent worldwide pandemic of COVID-19 has had a detrimental worldwide impact on people of all ages. Although data from China and the United States indicate that pediatric cases often have a mild course and are less severe in comparison to adults, there have been several cases of kidney failure and multisystem inflammatory syndrome reported. As such, we believe that the world should be prepared if the severity of cases begins to further increase within the pediatric population. Therefore, we provide here a position paper centered on emergency preparation with resource allocation for critical COVID-19 cases within the pediatric population, specifically where renal conditions worsen due to the onset of AKI.

Plasma exchange in ANCA-associated vasculitis: the pro position

Plasma exchange (PLEX) is capable of removing significant amounts of circulating antibodies. In anti-neutrophil cytoplasmic antibody-associated vasculitis, PLEX was reserved for patients with severe presentation forms such as rapidly progressive glomerulonephritis and pulmonary haemorrhage. The Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis (PEXIVAS) trial included all comers with a glomerular filtration rate <50 mL/min/1.73 m2 and thus aimed to answer the question of whether PLEX is an option for patients with no relevant kidney function impairment or not. PEXIVAS revealed that after a follow-up of almost 3 years, routine administration of PLEX does not provide an additional benefit to reduce the rate of a composite comprising end-stage kidney disease or death. In the absence of histological parameters, it is tempting to speculate whether PLEX is effective or not in those with a potential for renal recovery. A subset of patients presented with alveolar haemorrhage, and there was a trend towards a better outcome of such cases receiving PLEX. This would be in line with observational studies reporting a recovery of alveolar haemorrhage following extracorporeal treatment. In this PRO part of the debate, we highlight the shortcomings of the PEXIVAS trial and stimulate further research paths, which in our eyes are necessary before abandoning PLEX from the therapeutic armamentarium.

Clearance of chloroquine and hydroxychloroquine by the Seraph® 100 Microbinda Affinity Blood Filter -a device approved for the treatment of COVID-19 patients

On April 17 2020, the United States Food and Drug Administration granted Coronavirus Disease 2019 (COVID‐19) emergency use authorizations for the Seraph 100 Microbind Affinity Blood Filter. The medical device is aimed to treat critically ill COVID‐19 patients with confirmed or imminent respiratory failure. The aim of this life size in vitro pharmacokinetic study was to investigate the in vitro adsorption of chloroquine and hydroxychloroquine from human plasma using equipment that is also used at the bedside. After start of the hemoperfusion, Pre (C_pre) Seraph plasma levels were obtained at 5 (C₅), 10 (C₁₀), 15 (C₁₅), 30 (C₃₀), 60 (C₆₀), and 120 (C₁₂₀) minutes into the procedure. At two timepoints (5 and 120 minutes) post (C_post) Seraph plasma levels were determined that were used to calculate the plasma clearance of the Seraph. Both drugs were determined using a validated HPLC method. Median [IQR] plasma clearance of the Seraph for chloroquine/hydroxychloroquine was 1.71 [0.51‐4.38] mL/min/1.79 [0.21‐3.68] mL/min respectively. The lack of elimination was also confirmed by the fact that plasma levels did not change over the 120 minutes treatment. As neither chloroquine nor hydroxychloroquine were removed by the treatment with the Seraph dose adjustments in COVID‐19 patients undergoing this treatment are not necessary.

Removal of COVID-19 Spike Protein, Whole Virus, Exosomes, and Exosomal MicroRNAs by the Hemopurifier® Lectin-Affinity Cartridge in Critically Ill Patients With COVID-19 Infection

Coronavirus−19 (COVID-19) has rapidly spread throughout the world resulting in a significant amount of morbidity and mortality. Despite advances in therapy, social distancing, masks, and vaccination many places in the world continue to see an increase in the number of cases and deaths. Viremia is commonly present in severely ill patients with COVID-19 infections and is associated with organ dysfunction and poor outcomes. Exosomes released by activated cells have been implicated in the pathogenesis of COVID-19 infection. We report the experience of two cases of critically ill COVID-19 patients treated with the Hemopurifier; a lectin affinity cartridge designed to remove mannosylated viruses and exosomes. Both patients tolerated the Hemopurifier sessions without adverse effects. In the first patient removal of exosomes and exosomal microRNAs was associated with improved coagulopathy, oxygenation, and clinical recovery, while in a second patient removal of COVID-19 by the Hemopurifier cartridge was observed. The Hemopurifier is currently under further investigation in up to 40-patients in a safety and feasibility study in ICU patients with COVID-19 infection.

Successful management of clinical signs associated with hepatic encephalopathy with manual therapeutic plasma exchange in a dog

OBJECTIVE

To describe the use of manual therapeutic plasma exchange (TPE) to manage hepatic encephalopathy (HE) in a dog.

CASE SUMMARY

A 9-year-old neutered female Dachshund presented for HE secondary to a previously diagnosed portosystemic shunt. The hyperammonemia and severe clinical signs of HE persisted despite extensive medical management. Therapeutic plasma exchange was performed for stabilization prior to surgical shunt ligation. A total of 1 plasma volume was processed during a single manual TPE session. The ammonia immediately prior to TPE was 235 μmol/L (reference interval, 10-30 μmol/L) and decreased to 117 μmol/L by the end of the session. The dog showed significant improvement in clinical signs shortly after the session and remained stable thereafter. Shunt ligation was performed 5 days later with no complications observed with TPE or postoperatively. The dog was discharged 3 days after surgery with no neurological signs and was doing well 100 days after surgery.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first published report of manual TPE to manage HE in veterinary medicine. Therapeutic plasma exchange should be further investigated as a possible strategy to manage clinical signs of HE in patients that are refractory to medical management. Achieving this with manual TPE may be considered in patients that are too small for conventional TPE due to extracorporeal volume or in situations where conventional TPE is not available.

Antiviral Dosing Modification for Coronavirus Disease 2019-Infected Patients Receiving Extracorporeal Therapy

Previous literature regarding coronavirus disease 2019 outlined a presence of organ dysfunction including acute respiratory distress syndrome and acute kidney injury that are linked to mortality. Several patients require extracorporeal therapy. This review aims to gather available published resources including physicochemical and pharmacokinetic properties and suggests antiviral drug dosing adaptation for coronavirus disease 2019-infected critically ill patients receiving extracorporeal therapy. A literature search was performed using PubMed, clinical trial registries, and bibliographic review of textbooks and review articles. Unfortunately, no standard of pharmacologic management and recommendations of drug dosing for coronavirus disease 2019 infection for critically ill patients receiving extracorporeal therapy exist due to the limited data on pharmacokinetic and clinical studies. All available extracted data were analyzed to suggest the appropriate drug dosing adjustment. Antiviral drug dosing adjustments for critically ill patients receiving extracorporeal membrane oxygenation and continuous renal replacement therapy are presented in this review. Considering pathophysiologic changes, drug properties, and extracorporeal modalities, applying our suggestions is recommended.

Extracorporeal Hyperoxygenation Therapy (EHT) for Carbon Monoxide Poisoning: In-Vitro Proof of Principle

Carbon monoxide (CO) poisoning is the leading cause of poisoning-related deaths globally. The currently available therapy options are normobaric oxygen (NBO) and hyperbaric oxygen (HBO). While NBO lacks in efficacy, HBO is not available in all areas and countries. We present a novel method, extracorporeal hyperoxygenation therapy (EHT), for the treatment of CO poisoning that eliminates the CO by treating blood extracorporeally at elevated oxygen partial pressure. In this study, we proof the principle of the method in vitro using procine blood: Firstly, we investigated the difference in the CO elimination of a hollow fibre membrane oxygenator and a specifically designed batch oxygenator based on the bubble oxygenator principle at elevated pressures (1, 3 bar). Secondly, the batch oxygenator was redesigned and tested for a broader range of pressures (1, 3, 5, 7 bar) and temperatures (23, 30, 37 °C). So far, the shortest measured carboxyhemoglobin half-life in the blood was 21.32 min. In conclusion, EHT has the potential to provide an easily available and effective method for the treatment of CO poisoning.

High-efficiency, high-flux in-line hemofiltration using a high blood flow extracorporeal circuit

The ability of current renal replacement therapy modalities to achieve rapid solute removal is limited by membrane surface area and blood flow rate. Extracorporeal membrane oxygenation offers high blood flow and hemodynamic support that may be harnessed to overcome limitations in traditional renal replacement therapy. Using an extracorporeal membrane oxygenation circuit, we describe a high blood flow, high-efficiency hemofiltration technique using in-line hemofilters (hemoconcentrators) and standard replacement fluid to enhance solute clearance. Using this approach and a total of 5 L of replacement volume per treatment, creatinine (Cr) clearances of 8.3 L/hour and 11.2 L/hour using one and two hemoconcentrators, respectively, were achieved. With use of a high blood flow rate of up to 5 L/min, this hemofiltration technique can potentially offer clearance of 30 times that of continuous renal replacement therapy and of 6 times that of hemodialysis which may expand the ability to remove substances traditionally not considered removable via existing extracorporeal therapies.

Evaluation of nafamostat mesilate as an alternative anticoagulant during intermittent hemodialysis in healthy Beagle dogs

OBJECTIVE

To evaluate nafamostat mesilate (NM) as an alternative anticoagulant agent for intermittent hemodialysis (IHD).

DESIGN

Prospective randomized study.

SETTING

University teaching hospital.

ANIMALS

Eighteen healthy Beagle dogs.

INTERVENTIONS

In group 1 (n = 6), NM was administered at a dose of 0.5 mg/kg/h during IHD for 5 hours. In group 2 (n = 6), NM was administered at a low dose of 0.25 mg/kg/h during IHD. In group 3 (n = 6), which was the control group, unfractionated heparin (UFH) was administered during IHD. The evaluated parameters included: the amount of residual blood clots in the blood chamber and arterial side of the dialyzer; the levels of hemoglobin, hematocrit, and platelets; and the prothrombin time (PT), activated partial thromboplastin time (aPTT), and activated clotting time (ACT).

MEASUREMENTS AND MAIN RESULTS

Groups 1 and 2 successfully completed IHD without serious coagulation in the extracorporeal circulation. The residual blood clotting in the blood chamber and arterial side of the dialyzer did not significantly differ in groups 1 and 2 compared to group 3 (group 1 vs group 3, P = 1.000; and group 2 vs group 3, P = 1.000). No significant differences were observed between pre- and posttreatment PTs in groups 1 (P = 0.476) and 2 (P = 0.597), between pre- and posttreatment aPTTs in groups 1 (P = 0.983) and 2 (P = 0.977), and between pre- and posttreatment ACT in groups 1 (P = 0.282) and 2 (P = 0.401). In group 3, a significant elevation of ACT was observed at the posttest (P < 0.001).

CONCLUSIONS

The results of this study in healthy Beagle dogs suggest that NM at 0.25 mg/kg/h may be a valid alternative to UFH for IHD. Further studies are needed in patients at high risk of bleeding.

Ultrafiltration during intermittent hemodialysis in dogs with acute kidney injury

BACKGROUND

Ultrafiltration is performed to alleviate fluid overload in dogs with acute kidney injury (AKI) undergoing intermittent hemodialysis (IHD).

OBJECTIVES

To describe prescription patterns for ultrafiltration in dogs receiving IHD for AKI and risk factors for ultrafiltration-related complications.

ANIMALS

Seventy-seven dogs undergoing 144 IHD treatments between 2009 and 2019.

METHODS

Medical records of dogs receiving IHD for AKI were reviewed. The initial 3 IHD treatments in which ultrafiltration was prescribed were included. Ultrafiltration-related complications were defined as those requiring an intervention such as transient or permanent discontinuation of ultrafiltration.

RESULTS

Mean fluid removal rate per treatment was 8.1 ± 4.5 mL/kg/h. Ultrafiltration-related complications occurred in 37/144 (25.7%) of treatments. Hypotension was rare (6/144, 4.2% of treatments). No ultrafiltration-related complications resulted in deaths. The mean prescribed fluid removal rate per treatment was higher in dogs with ultrafiltration-related complications than without (10.8 ± 4.9 mL/kg/h vs 8.8 ± 5.1 mL/kg/h, respectively; P = .03). The mean delivered fluid removal rate per treatment was significantly lower in dogs with UF-related complications compared to those without complications (6.8 ± 4.0 mL/kg/h vs 8.6 ± 4.6 mL/kg/h, respectively; P = .04). Variables associated with ultrafiltration-related complications (P < .05) included central venous oxygen saturation, body temperature before IHD treatment, total extracorporeal circuit volume and BUN at the end of IHD treatment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Ultrafiltration during IHD in dogs with AKI is overall safe. Higher prescribed ultrafiltration rates were associated with increased risk of complications. Decrease in central venous oxygen saturation is associated with ultrafiltration-related complications, emphasizing the utility of in-line blood monitoring.

Treatment of acute kidney injury secondary to oak intoxication with hemodialysis in a miniature zebu

OBJECTIVE

To describe the successful management of acute kidney injury (AKI) secondary to oak intoxication using hemodialysis in a miniature zebu.

CASE SUMMARY

A 1-year-old male intact miniature zebu was presented for evaluation of a 2-day history of lethargy, anorexia, decreased urine production, and dry, firm stool. Initial diagnostics revealed severe azotemia and the bull was presumptively diagnosed with AKI secondary to oak intoxication due to free access to oak trees in the pasture. Despite conventional management with IV fluids and supportive therapy, the degree of azotemia progressively worsened, and the bull became oliguric and fluid overloaded. Two treatments with hemodialysis resulted in reduction of azotemia and ketonemia, and resolution of fluid overload and oliguria. The zebu was discharged from the hospital after 10 days of hospitalization.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first reported case using hemodialysis for AKI in a bovid. Treatment with hemodialysis was effective in this case resulting in rapid resolution of azotemia, fluid overload, and oliguria. Hemodialysis may hasten the recovery and decrease morbidity and mortality in bovids with AKI.

[Extracorporeal treatment of nucleoprotein disposal disorders using the systemic lupus erythematosus model: evaluation of efficacy and safety in a short-term simulated experiment]

Efficacy and safety of the extracorporeal blood perfusion through DNase I- and C1q-containing magnetic beads have been evaluated using the experimental model simulating the nucleoprotein disposal disorders in systemic lupus erythematosus (SLE). The study was performed using 20 rats in which the essential impairments of nucleoprotein catabolism typical for SLE were modeled. The animals were randomized into the experimental group and the placebo perfusion control group. Rats of the experimental group were characterized by the statistically significant reduction of increased levels of circulating immune complexes and plasma DNA as well as diminished levels of plasma creatinine and kidney IgG deposition as compared with placebo controls. During short-term experiment there were neither animal deaths nor substantial blood cell destruction and hepatotoxicity signs.

Hemodialysis as emergency treatment of a severe baclofen intoxication in a 3 kg dog

OBJECTIVE

To describe the clinical efficacy and drug removal kinetics of hemodialysis (HD) as emergency treatment in a small size dog with severe baclofen intoxication.

CASE DESCRIPTION

A 2-year-old dog was presented in stupor to the emergency service a few hours after ingestion of up to 25 mg of baclofen. Medical stabilisation was attempted but was unsuccessful in improving the neurological condition and the patient rapidly progressed to coma. A 4-h session of HD was performed in emergency with near complete resolution of neurological signs and only mild disorientation by the end of the treatment. No adverse side effects occurred during HD. Baclofen concentration was measured serially during the session. Drug extraction ratio, clearance and mass removal by the dialyser were calculated. Dialytic elimination rate constant (K_d ) was seven times higher than the intrinsic elimination rate constant (K_intr ) and the half-life (t½) during HD was nearly nine times shorter than the endogenous one.

NEW OR UNIQUE INFORMATION PROVIDED

This is the first case report providing pharmacokinetic data associated with HD treatment of severe baclofen intoxication in a dog.

Successful management of severe carprofen toxicity with manual therapeutic plasma exchange in a dog

OBJECTIVE

To report the use of manual therapeutic plasma exchange (TPE) in a dog with severe carprofen toxicity.

SUMMARY

A 12-year-old neutered female Pembroke Welsh Corgi weighing 20 kg was evaluated after ingesting 223 mg/kg of carprofen. Emesis was attempted with apomorphine at the primary care veterinarian but was unsuccessful, and a dose of activated charcoal with sorbitol was administered. On presentation to the referral center, approximately 8 hours after ingestion, the dog's physical examination revealed mild abdominal discomfort but was otherwise unremarkable. Treatment consisted of a combination of supportive care including activated charcoal with sorbitol, cholestyramine, IV lipid emulsion, and manual TPE. Blood samples were collected prior to the initiation of manual TPE and at the completion of 12 exchange cycles. Carprofen levels were determined by high-pressure liquid chromatography. A 57% decrease in carprofen levels was achieved with the combination of activated charcoal, cholestyramine, IV lipid emulsion, and manual TPE. The dog did not develop organ dysfunction secondary to toxicity and was discharged 4 days after ingestion.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes the successful decrease of plasma carprofen in a dog with the combination of decontamination techniques and manual TPE. While TPE has been previously reported as a successful therapeutic in dogs with nonsteroidal anti-inflammatory toxicity, including carprofen, equipment and expertise of this platform is not readily available. Manual TPE is technically simple and can be performed in any hospital with a large blood centrifuge.

[Intoxications in nephrology: clinical cases and local experience in Sciacca Hospital]

Intoxications are a common problem all over the world and cause acid-base balance disturbances, dysionias or acute renal failure; they can develop rapidly leading to severe cellular dysfunction and death. Intoxications and drug overdoses often require the intervention of Nephrologists, for the correction of acidosis, the administration of selective inhibitory enzymes and also hemodialysis treatment. Extracorporeal therapies have been used to remove toxins for over fifty years and have acquired an increasing role, thanks to the use of new treatment modalities in intoxicated patients. In our clinical practice in the Covid period we have found an increase in clinical cases of intoxication with psychiatric drugs, including benzodiazepines, clozapine, lithium, quetiapine and cocaine.

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

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.

Effective removal of gadolinium with hemodialysis in a dog with severe acute on chronic kidney injury

OBJECTIVE

To describe the use of intermittent hemodialysis (IHD) to remove gadolinium (28.1 mg/kg dose) in a dog with severe kidney disease.

CASE SUMMARY

A 12-year-old neutered female Yorkshire Terrier presented with severe acute-on-chronic kidney injury and concurrent neurological signs. The dog received extracorporeal therapy as part of management. Uremia improved after hemodialysis, but central nervous system signs persisted; therefore, a contrast-enhanced magnetic resonance imaging was performed, immediately followed by IHD. Two IHD treatments with a low-flux dialyzer were performed 1.5 and 25.75 hours after administration of gadolinium, with almost complete removal of gadolinium. More than 96% of gadolinium was removed with a single treatment.

NEW OR UNIQUE INFORMATION PROVIDED

Extracorporeal therapy is effective at removing gadolinium-based chelated contrast agents and could be considered if magnetic resonance imaging is indicated in a patient with substantial kidney impairment. Alternatively, newer contrast agents that have been deemed safer in this patient population could be used.

Survival benefit of resin cartridge extracorporeal blood purification therapy in patients with septic shock

BACKGROUND/AIM

Extracorporeal blood purification (EBP) therapies have shown promise as potential rescue treatments for patients with septic shock. However, precise evidence regarding their effectiveness is lacking. This case-control study aimed to evaluate the 28-day survival benefit of a resin cartridge-based EBP therapy compared to conventional therapies in patients with septic shock.

MATERIALS AND METHODS

The study sample was collected retrospectively from the medical records of patients admitted to the intensive care unit (ICU) between 2015 and 2020. The study included patients with septic shock aged ≥18 years who had ICU stays >96 h and excluded those lost to follow-up by 28 days or readmitted. First, 28-day survival was compared between EBP patients and 1:1 matched conventionally treated controls. Second, the EBP patients were evaluated for clinical and laboratory improvements within 72 h of EBP therapy.

RESULTS

Of 3742 patients, 391 were included in this study, of whom 129 received EBP therapy and had a 28-day survival rate of 44%, compared to 262 matched controls who received conventional therapy alone and had a survival rate of 33% (p = 0.001, log-rank = 0.05, number needed to treat = 8, and odds ratio = 1.7). After receiving EBP therapy for 72 h, improvements were observed in the Sequential Organ Failure Assessment scores (p < 0.05), shock indices (p < 0.05), partial pressure of oxygen in the arterial blood to the fraction of inspiratory oxygen concentration ratios (p < 0.001), vasopressor requirements (p < 0.001), pH (p < 0.05), lactate levels (p < 0.001), and C-reactive protein levels (p < 0.05).

CONCLUSION

The findings suggest that administering resin cartridge-based EBP therapy to patients with septic shock may improve their survival compared to conventional therapies.

Efficacy of hemoadsorption in the severe course of COVID-19

Introduction

Insufficiencies of the majority of targeted therapies for the most severe, life-threatening forms of COVID-19 warrant alternative, adjuvant treatment options for enhanced life maintenance that include extracorporeal blood purification and homeostasis support. The goal of the current study is to evaluate the clinical efficacy of hemoadsorption with mesoporous hypercrosslinked polystyrene beads (Efferon CT single-use cartridge) in an expanded cohort of patients with severe and critical COVID-19 resistant to antibody therapies and requiring post-therapy invasive mechanical lung ventilation (MLV) versus parameter-matched control group with no hemoadsorption.

Materials and methods

A single-center cohort study (NCT06402279) enrolled patients from October 2020 to February 2022: the Efferon CT group (non-responders to anti-cytokine antibody therapy requiring IMV, hemadsorption, and standard treatment, n = 65) and retrospectively acquired propensity-matched control group (no hemadsorption, standard treatment only, n = 65).

Results

This observational study revealed the capability of Efferon CT hemoadsorption to safely, rapidly, and significantly reduce the need for norepinephrine, increase the oxygenation index, prevent the sepsis-associated AKI, decrease the development of multiorgan failure, and restore the immune system balance by decreasing pro-inflammatory IL-6, ferritin levels, and neutrophil-to-lymphocyte ratio.

Conclusion

The clinical efficiency of hemoadsorption using Efferon CT was confirmed by the resolution of acute respiratory failure in 54% of patients, significantly increasing the number of days without mechanical ventilation and increasing early the index of oxygenation. Most importantly, the hemoadsorption with Efferon CT was safe and resulted in a significant decrease in the mortality of severe COVID-19 patients.

Clinical trial registration

www.clinicaltrials.gov, Identifier NCT06402279.

Feasibility of hemoperfusion using extracorporeal therapy in the horse

Objective

Develop, implement, and monitor for adverse effects of, a novel hemoperfusion therapy in adult horses.

Methods

A prospective, observational feasibility study using three healthy adult horses from the North Carolina State University teaching herd. Health status was determined by physical exam, complete blood count, coagulation panel, and serum biochemistry. Each horse was instrumented with a 14 Fr × 25 cm double-lumen temporary hemodialysis catheter and underwent a 240 min polymer-based hemoperfusion session. Horses were administered unfractionated heparin to maintain anti-coagulation during the session. Given the novelty of this therapy in horses, each horse was treated as a learning opportunity that informed an iterative process of protocol development and modification.

Measurements and main results

Our long-term goal is to investigate potential clinical applications of hemoperfusion in horses, including cytokine reduction in horses with severe SIRS/sepsis. Horses were monitored for changes in clinical exam, biochemistry and hematology parameters. Additionally, cytokines were quantified to determine whether extracorporeal hemadsorption therapy alone caused an inflammatory response. Our results show that hemoperfusion therapy was associated with decreased platelet counts and serum albumin concentration. There was no significant change in plasma cytokine concentrations with hemoperfusion therapy. In one horse, the cytokine concentrations decreased, as previously reported with hemoperfusion therapy in humans.

Hypothesis

We hypothesized that hemoperfusion therapy could be performed in healthy adult horses without significant adverse effects.

Conclusion

Polymer-based hemoperfusion is a feasible extracorporeal therapy (ECT) modality for adult horses. Additional studies are needed to further establish clinical protocols, as well as establish efficacy of polymer-based hemoperfusion for treatment of various conditions in horses, including intoxications, immune-mediated conditions, and sepsis.

Successful treatment of a severe 5-hydroxytrytophan intoxication using carbon hemoperfusion, hemodiafiltration, and mechanical ventilation in a dog

OBJECTIVE

To describe the successful use of carbon hemoperfusion and hemodiafiltration in combination with mechanical ventilation (MV) to treat a severe intoxication of 5-hydroxytryptophan (5-HTP) in a dog.

CASE SUMMARY

A dog ingested a minimum of 550 mg/kg of extended-release 5-HTP, resulting in serotonin syndrome that progressed to a comatose state and severe hypoventilation requiring MV. Extracorporeal carbon hemoperfusion coupled with hemodiafiltration was performed to remove 5-HTP from this patient. A carbon hemoperfusion cartridge was placed in series upstream in the extracorporeal circuit from the hemodialyzer. A total of 46.5 L of blood (4.89 L/kg) was processed during a 4.85-hour treatment. Serial plasma samples were obtained at 0, 60, 90, and 150 minutes during the session and 14 hours after the session. These samples were later analyzed for 5-HTP and serotonin concentrations. The extraction ratio of 5-HTP was 93.6%-98.9% through the carbon filter. The dog was weaned from MV within 8 hours after extracorporeal therapy and, after a full recovery, was successfully discharged.

NEW OR UNIQUE INFORMATION PROVIDED

Despite an extensive review of the available literature, this appears to be the first reported case of using a carbon hemoperfusion, hemodiafiltration, and MV to treat severe serotonin syndrome secondary to 5-HTP intoxication in a dog. The combination of carbon hemoperfusion and hemodiafiltration can significantly reduce plasma 5-HTP concentrations after acute intoxication and may serve to decrease morbidity and mortality in patients with severe intoxication.

Extracorporeal Therapy in Dermatology

Extracorporeal therapy is a treatment modality where human blood undergoes favorable technical modifications and is reintroduced into the same patient. Since the last four decades this technique has been deployed in the management of difficult and refractory disorders in dermatology. Over a period of time newer techniques like immunoadsorption has emerged and opened new vistas in management of morbid dermatoses. In extracorporeal photopheresis a patient's leukocytes are separated and treated outside with Ultra Violet A in presence of 8-methoxypsoralen. Double filtration plasmapheresis and Immunoadsorption are techniques to remove offending immune complexes. They are safe and reduce the need of toxic medications that are conventionally used in recalcitrant skin diseases. In recent years immunoadsorption is emerging as first-line therapy in condition like immunobullous diseases. High cost is one of the important factors limiting their wider use in developing countries like India. Our review discusses different extracorporeal therapies, their applications, recommendations and guidelines based on various clinical trials.