Cytokine release syndrome is prevalent in severe cases of COVID-19. In this syndrome, an uncontrolled response of immune system occurs. Extracorporeal blood purification has been proven to effectively remove the released inflammatory cytokines. Here, we reported a successful case to represent our experience of extracorporeal blood purification in a patient with severe COVID-19. Â© 2020 The Author

Abedini, A.

Adnani, N.

Dastan, F.

Hashemian, S.M.

Jamaati, H.

Kiani, A.

Mortazavi, S.M.

Saffaei, A.

Samiee Roudi, S.

eprints Iran University of Medical Sciences

Journal of Global Antimicrobial Resistance 21 (2020) 340–341Short communicationContinues renal replacement therapy (CRRT) with disposablehemoperfusion cartridge: A promising option for severe COVID-19Farzaneh Dastana,b, Ali Saffaeic, Seyed Mehdi Mortazavib, Hamidreza Jamaatib,Nadia Adnanid, Sasan Samiee Roudie, Arda Kianif, Atefeh Abedinib,Seyed MohammadReza Hashemianb,*aDepartment of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IranbChronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti Universityof Medical Sciences, Tehran, Iranc Student Research Committee, Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IrandNephrology Research Center, Department of Nephrology, School of Medicine, Alborz University of Medical Sciences, Karaj, Irane Infectious Research Center, Department of Infectious Disease, School of Medicine, Iran University of Medical Sciences, Tehran, Iranf Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences,Tehran, IranA R T I C L E I N F OArticle history:Received 1 April 2020Received in revised form 9 April 2020Accepted 16 April 2020Available online 27 April 2020Keywords:COVID-19Continues renal replacement therapyHemoperfusionAcute respiratory distress syndromeA B S T R A C TCytokine release syndrome is prevalent in severe cases of COVID-19. In this syndrome, an uncontrolledresponse of immune system occurs. Extracorporeal blood purification has been proven to effectivelyremove the released inflammatory cytokines. Here, we reported a successful case to represent ourexperience of extracorporeal blood purification in a patient with severe COVID-19.© 2020 The Authors. Published by Elsevier Ltd on behalf of International Society for AntimicrobialChemotherapy. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Contents lists available at ScienceDirectJournal of Global Antimicrobial Resistancejournal home page : www.e l sev ier .com/ loca te / jgarA 54-year old man presented to the emergency department ofErfan Niyayesh Hospital, Tehran, Iran, with complains of high-gradefever,cough,anddyspneaforfivedays.Atadmission time,hehadfeverupto 38 C. Peripheral oxygen saturationwas 90% with a face mask.Noabnormality was seen in laboratory results except positive C-reactiveprotein, lymphopenia with 570 cells/mL, and severe respiratoryacidosis. The chest X-ray imaging revealed bilateral infiltration inboth upper and lower lobs (Fig. 1a). The patient had no underlyingdiseases and history of medicine usage. Reverse transcription-polymerase chain reaction (RT-PCR) sample for COVID-19 wasreported positive and according to RT-PCR test and clinical symptoms,the diagnosis of COVID-19 was made for the patient. The therapeuticregimen included Hydroxychloroquine at a dose of 200 mg P.O. BIDand lopinavir/ritonavir at a dose of 200/50 mg P.O. BID initiated for thepatient. After four days, the clinical condition of the patient wasdeteriorated and he was subjected to intubation for invasivemechanical ventilation. The peripheral oxygen saturation decreased* Corresponding author.E-mail address: iran.criticalcare@yahoo.com (S.M. Hashemian).http://dx.doi.org/10.1016/j.jgar.2020.04.0242213-7165/© 2020 The Authors. Published by Elsevier Ltd on behalf of International SocietND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).to 82%. The chest X-ray imaging showed the progressive infiltration(Fig. 1b) and the patient was categorized as a critically COVID-19 casewith remarkable acute respiratory distress syndrome (ARDS). Theplasma level of interlukin-1 (IL-1), IL-6, IL-8, and tumor necrosis factoralpha were measured at this time. The results showed high levels ofinflammatory cytokines. The urine output also decreased to 200 mLduring the last 12 h and creatinine increased to 1.5 mg/dL. At this time,it is decided to start continuous renal replacement therapy (CRRT,Prismaflex, Baxter, IL, USA) with disposable hemoperfusion cartridge(HA 380 cartridge, Jafron Biomedical Co., China) due to cytokinerelease storm and hypoxemia. A Shaldon catheter was inserted andCRRT was done for three sessions. The CRRT modality was continuousveno-venous hemofiltration (CVVH). The replacement fluid volumewas removed by 35 mL/kg/h and the pump circulated blood by250 mL/min. Priming of hemoperfusion was done with saline, and thecartridge was primed in a vertical positionwith the arterial side facingdownward. A bolus dose of 2500 IU of heparin was administered intothe arterial line, the cartridge was kept inlet sidedown, and blood flowthrough the cartridge wasbegun. Totally, 6000 IU was neededthroughthe procedure. CRRT was started with a high ultrafiltration rate(200 mL/h). Each cartridgewasreplacedwith a newcartridge after6 h.y for Antimicrobial Chemotherapy. This is an open access article under the CC BY-NC-Fig. 1. The chest X-ray of the patient during hospitalization (a; admission time, b; before hemoperfusion, c; after hemoperfusion).F. Dastan et al. / Journal of Global Antimicrobial Resistance 21 (2020) 340–341 341The fluid removal rate was decreased to 50 mL/h after 8 h and then tozero mL/h during the last 8 h in the first 24 h. The second and the thirdsessions of CRRT were conducted by 0 mL/h fluid removal. A 24-h restbetween sessions, was considered to avoid the probable coagulopathyand electrolyte abnormality. After three sessions of CRRT plushemopurification, the clinical condition of the patient was improvedwith the peripheral oxygen saturation of 95%. The creatinine alsodecreased to 1.1 mg/dL after the end of CRRTand urine output reachedto 70 mL/h. No laboratory abnormality was seen during the CRRT. Thechest X-ray revealed recovery of both lungs following the completionof 3 sessions of hemopurification (Fig. 1c). Also, the inflammatorycytokines were measured 48 h following the last session ofhemoperfusion and showed a remarkable decrease. IL-1, and IL-6were decreased from 523.3 pg/mL to 38.25 pg/mL, and 226.35 pg/mLto 210.18 pg/mL, respectively. The measurements also showed thedecrease in IL-8 from 886.5 pg/mL to 482.4 pg/mL. Tumor necrosisfactor alpha level decreased from 49.5 pg/mL to 47.3 pg/mL at the endof 3 sessions of hemoperfusion. The patient was finally transferred tothe ward with an acceptable clinical condition.The “cytokine cascade” in patients with new coronavirus(COVID-19) is a leading cause of death in critically ill patients [1]. Avariety of blood purification technology treatment methods suchas CRRT plus hemoperfusion seem to be effective in certain cases.Cytokine release storm is the probable Phenomenon in severeCOVID-19 cases [2]. Extracorporeal organ support can not onlysupport vital organ functions such as the heart, lungs, kidneys, andliver but also avoid organ damage by removing excess inflamma-tory mediators [3]. Extracorporeal blood purification technologyhas been proven to effectively eliminate inflammatory cytokinessuch as CRP, IL-1, IL-6, etc. [4]. Here, we reported a successful caseto represent our experience of extracorporeal blood purification ina patient with confirmed COVID-19. In this case, IL-6 was high andTocilizumab, as an IL-6 antagonist, was another potential agent.However, Tocilizumab therapy may be associated with adverseeffects and the access to Tocilizumab is limited in Iran. Also,tocilizumab is effective only on IL-6 regarding its mechanism.Hemoperfusion can have impact on more than one cytokine andmay be more effective. This case responded to hemoperfusion andCRRT without remarkable complication. Hence, hemoperfusionwith a disposable cartridge may be a promising option to decreasethe inflammatory cytokines in COVID-19 induced ARDS. However,it is necessary to conduct clinical trials to find the efficacy andsafety of this strategy.FundingNoneWritten informed consentObtained.Conflict of interestNone.References[1] Channappanavar R, Perlman S. Pathogenic human coronavirus infections:causes and consequences of cytokine storm and immunopathology. Seminars inimmunopathology. Springer; 2017. p. 529–39.[2] Zhou Y, Fu B, Zheng X, Wang D, Zhao C, qi Y, et al. Pathogenic T cells andinflammatory monocytes incite inflammatory storm in severe COVID-19patients. Natl Sci Rev 2020.[3] MacLaren G, Fisher D, Brodie D. Preparing for the most critically ill patients withCOVID-19: the potential role of extracorporeal membrane oxygenation. JAMA 2020.[4] Venkataraman R, Subramanian S, Kellum JA. Clinical review: extracorporealblood purification in severe sepsis. Crit Care 2003;7:139.

Continues renal replacement therapy (CRRT) with disposable hemoperfusion cartridge: A promising option for severe COVID-19

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Continues renal replacement therapy (CRRT) with disposable hemoperfusion cartridge: A promising option for severe COVID-19

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