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

Real-World Outcomes of Hemoadsorption with CytoSorb® in Patients with Septic Shock: Insights from a Single-Center Study

BackgroundHemoadsorption is currently employed to treat septic shock and other clinical conditions involving massive inflammatory mediator release. CytoSorb®, a device utilizing synthetic resin microbeads, provides a large adsorption surface for blood purification. This study aimed to review the clinical course of patients with septic shock treated with CytoSorb® in our hospital's intensive care unit (ICU).Patients and MethodsThis study retrospectively analyzed the clinical course of patients with septic shock treated with CytoSorb®, focusing on treatment timing and the volume of blood processed.ResultsBetween July 1, 2016, and December 31, 2023, 175 patients (106 men, 69 women; median age: 67 years, interquartile [IQR]: 58-85) received CytoSorb® therapy. Survivors exhibited a significantly lower simplified acute physiology score at admission than nonsurvivors. CytoSorb® was initiated within 24 h of shock onset in 102 patients (58%, early starters) and between 25 and 48 h in 73 patients (42%, late starters). Hemodynamic improvements elevated mean arterial pressure and reduced lactate, procalcitonin, C-reactive protein, sequential organ failure assessment scores, and noradrenaline doses in survivors. These effects were more pronounced in early starters receiving intensive treatment, who also demonstrated significantly lower lactate levels and higher mean arterial pressure at the end of therapy. Overall, 86 patients (49%) died in the ICU. Survivors underwent longer treatment durations and processed greater blood volumes than nonsurvivors.ConclusionsIn patients with septic shock treated with CytoSorb® within 48 h of onset, treatment intensity-rather than timing-was associated with lower ICU mortality rates.

Hemoperfusion with CytoSorb® in Pediatric Patients: A Monocentric Case Series

Background: Pro- and anti-inflammatory cytokines help regulate the inflammatory response. A cytokine storm is a dysregulated cytokine response associated with sepsis and other conditions that result in a hyper-inflammatory state. Extracorporeal cytokine adsorption has the potential to restore a balanced inflammatory response. Hemoperfusion with CytoSorb® (CS) appears to be a short-term mode of treatment of sepsis in both adults and children. Objective: We present a case series of eight critically ill children involving the use of hemoperfusion with CS at the University Medical Center Ljubljana to treat clinically manifested cytokine storm. Results: In our preliminary experience, it was applied without complication in five children weighing more than 10 kg, who all survived. The effect of age on complications regarding CS treatment is unclear, yet in our case series, all three patients weighing less than 10 kg died of their disease. Conclusions: In our preliminary experience, cytokine adsorption with CS remains a potential adjunctive treatment for cytokine storm in critically ill children.

Systematic review with expert consensus on use of extracorporeal hemoadsorption in septic shock: An Indian perspective

BACKGROUND

Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters. Despite standard therapy, the outcomes are poor. Newer adjuvant therapy, such as CytoSorb® extracorporeal haemoadsorption device, has been investigated and shown promising outcome. However, there is a lack of some guidance to make clinical decisions on the use of CytoSorb® haemoadsorption as an adjuvant therapy in septic shock in Indian Setting. Therefore, this expert consensus was formulated.

AIM

To formulate/establish specific consensus statements on the use of CytoSorb® haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario.

METHODS

We performed a comprehensive literature on CytoSorb® haemoadsorption in sepsis, septic shock in PubMed selecting papers published between January 2011 and March 2023 2021 in English language. The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps. Using a modified Delphi approach combining evidence appraisal and expert opinion, the following topics related to CytoSorb® in septic shock were addressed: need for adjuvant therapy, initiation timeline, need for Interleukin -6 levels, duration of therapy, change of adsorbers, safety, prerequisite condition, efficacy endpoints and management flowchart. Eleven expert members from critical care, emergency medicine, and the intensive care participated and voted on nine statements and one open-ended question.

RESULTS

Eleven expert members from critical care, emergency medicine, and the intensive care participated and voted on nine statements and one open-ended question. All 11 experts in the consensus group (100%) participated in the first, second and third round of voting. After three iterative voting rounds and adapting two statements, consensus was achieved on nine statements out of nine statements. The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb® for all indications in the open-ended question (Q10) focusing on "future recommendations for CytoSorb® therapy".

CONCLUSION

This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb® haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.

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).

The Techniques of Blood Purification in the Treatment of Sepsis and Other Hyperinflammatory Conditions

Even in the absence of strong indications deriving from clinical studies, the removal of mediators is increasingly used in septic shock and in other clinical conditions characterized by a hyperinflammatory response. Despite the different underlying mechanisms of action, they are collectively indicated as blood purification techniques. Their main categories include blood- and plasma processing procedures, which can run in a stand-alone mode or, more commonly, in association with a renal replacement treatment. The different techniques and principles of function, the clinical evidence derived from multiple clinical investigations, and the possible side effects are reviewed and discussed along with the persisting uncertainties about their precise role in the therapeutic armamentarium of these syndromes.

Comparison of the CytoSorb® 300 mL and Jafron HA380 hemoadsorption devices: an in vitro study

INTRODUCTION

We performed an analysis of two blood purification systems to determine their performance for removing interleukins (ILs)-6 and 10, tumor necrosis factor (TNF)-α and monocyte chemoattractant protein (MCP)-1 from blood.

MATERIAL AND METHODS

An in vitro hemoperfusion blood recirculation circuit was used to compare the CytoSorb^® 300 mL (CytoSorbents Inc., Princeton, NJ) and Jafron HA 380 (Jafron Biomedical Co., Ltd., Zhuhai City, China) devices. The removal of purified recombinant human IL-6, IL-10, TNFα and MCP-1 by the adsorbers was compared at various timepoints. Three runs were completed and removal was evaluated as the mean area under the curve (AUC).

RESULTS

Both devices showed effective removal of the tested cytokines. IL-6, IL-10, TNFα and MCP-1 were removed faster and to a higher extent by the CytoSorb^® 300 mL device. At maximal time of 12 h, overall removal according to AUC of remaining concentrations was significantly lower with CytoSorb^® 300 mL compared with HA 380 (IL-6: 1075.5 ± 665.9 vs. 4345.1 ± 1499.3 (p = 0.01), IL-10: 5065.7 ± 882.5 vs. 11,939.7 ± 4523.1 (p = 0.03), TNF-α: 6519.9 ± 997.6 vs. 10,303.7 ± 2347.0 (p = 0.03) and MCP-1: 278.9 ± 40.7 vs. 607.3 ± 84.4 (p = 0.001)).

CONCLUSIONS

Both the CytoSorb^® and the Jafron HA 380 devices are capable of removing cytokines from blood in a benchtop model. The CytoSorb^® 300 device was significantly more efficient achieving the bulk of the removal in the first 120 min.

Urgent Coronary Artery Bypass Grafting Complicated by Systemic Inflammatory Response from Fulminant Herpes Zoster Successfully Managed with Adjunct Extracorporeal Hemoadsorption: A Case Report

Blood purification by hemoadsorption therapy seems to improve outcomes in selected patients undergoing cardiac surgery with cardiopulmonary bypass. Here, we report the successful application of hemoadsorption in the severe systemic inflammatory response during coronary artery bypass surgery in a patient with reactivated herpes zoster.

The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents

The extracorporeal elimination of a pathogen or damage-associated molecular pattern via blood purification techniques is increasingly being used in patients with septic shock and other clinical conditions characterized by a life-threatening inflammatory response. The removal of these substances can be accomoplished by means of ultrafiltration or hemoadsorption. Independently from the blood putification technique used, they could also affect the clearance of antibacterial and antifungal agents with a potentially significant clinical impact. In our review, we describe the basic principles of ultrafiltration and hemoadsorption, the available devices for this latter and the existing experimental and clinical studies; the final paragraph is dedicated to practical considerations that can help clinicians to consider the clearance of antibiotics and antifungals attributable to these techniques to minimize the risk of a iatrogenic underdosage.