The virus and the kidney
by Prof. Claudio Ronco
- Cytokine storm defined as massive activation of the immune system with release of cytokines and activation of all cells of immune system, cytokine storm presents with fever, myalgia, cough, shortness of breath, fatigue, low albumin level, elevated CRP/ESR/LDH/ferritin and IL-6 levels. Severe complication of COVID-19 involving releasing of TNF-Y, TNF-a2, TNF-a, IL-1, IL-6, IL-12, IL-17, IL-18 and this may lead to acute lung injury and hemodynamic instability with hypotension and need for vasopressor, altered coagulation, renal failure, and systemic capillary failure syndrome.
- We have today special neutral macroporous resins cartridges (HA130, HA230, HA330, HA380) which have been studied in our institution, the results showed that the cartridges have a high biocompatibility and optimal flow distribution.
- Kidney involvement in covid-19 and rationale for extracorporeal therapies suggests blood purification to remove cytokines such as direct hemoperfusion which use neutral macroporous sorbent, plasma adsorption etc.
- Chinese National Health commission of people republic of china also has suggested blood purification including PE, HP etc. to remove inflammatory factors and block cytokine storm.
- Case of covid-19 with cytokine storm: after admission, patient has fever, hypotension, respiratory failure, mechanical ventilation, hemodynamic instability, high cytokine levels, high ferritin level, high CPR level, and after HP treatment with HA380 cartridge showed hemodynamic stability, normalization of cytokine levels, improving in inflammatory parameters, improvement of P/F ratio and finally extubated.
- Other case, after treatment using HA380 showed a significant reduction of IL-6 and norepinephrine dosage used and improvement of MAP and ability to do phagocytosis. Also, antigen presentation capacity seen to be improved determined by the measurement of HLA DR expression.
- Establishing RCT to evaluate the hemoperfusion therapy on COVID-19 patients seems to be difficult, however we need to collect more information to clarify the role of hemoperfusion and other extracorporeal support.
Cytokine storm in septic shock: Practical aspects and experience in Latin America
By: by Dr. Rafael Avila
- Sepsis is a life-threatening condition that occurs when the host’s response to an infection causes organ dysfunction. This is caused by a dysregulated and excessive response of the host immune system (SEPSIS-3(2016)).
- Early detection and management of Cytokine response after sepsis may reduce the progression of the disease and hemoperfusion can be considered for alleviation of this response.
- The inclusion criteria for the study performed in our hospital using HA330
for septic shock patients were : Age > 18 years old, Procalcitonin (PCT) ≧ 2 ng/mL, IL-6 > 900 pg/ml, Septic shock (Sepsis-3), Norepinephrine ≧ 0.4 μg/kg/min, Need for renal replacement therapies or ECMO, and the maximum tolerated period to begin hemoperfusion was 12 hours.
- Primary: compare changes in norepinephrine requirements before and after hemoperfusion (HP) treatment. Secondary: Demonstrate the decrease in levels of IL-6, Assess the total and individual change of SOFA, Establish the resolution of shock, Clearance of lactate, Mortality (7, 30 and 60 days).
- The initial results from this study showed reduced cytokines level, decreased lactate levels and alleviation of macrophage activation — like syndrome.
- Antimicrobials administration should be adjusted in case of blood purification.
- Timing and intensity of hemoperfusion treatment is important to determine the results.