Antithrombotic drug removal with hemoadsorption during off-pump coronary artery bypass grafting

BACKGROUND

Patients requiring coronary artery bypass grafting (CABG) are often loaded with antithrombotic drugs (AT) and are at an increased risk for perioperative bleeding complications. Active AT removal by a hemoadsorption cartridge integrated in the cardiopulmonary bypass circuit is increasingly used in this setting to reduce bleeding, and herein we describe the extension of this application in patients on AT undergoing off-pump coronary artery bypass (OPCAB).

METHODS

Ten patients (80% male; mean age: 67.4 ± 9.2years) were treated with ticagrelor (eight patients), rivaroxaban and ticagrelor (one patient), and rivaroxaban (one patient) prior to OPCAB surgery. AT's were discontinued one day before surgery in nine patients and on the day of surgery in one patient, and all patients were also on aspirin. The cohort mean EuroSCORE-II was 2.9 ± 1.5%. A hemoadsorption cartridge was integrated into a dialysis device (n=4) or a stand-alone apheresis pump (n=6) periprocedural, for a treatment time of 145 ± 33 min. Outcome measures included bleeding according to Bleeding Academic Research Consortium (BARC)-4 and 24-hour chest-tube-drainage (CTD).

RESULTS

Mean operation time was 184 ± 35 min. All patients received a left internal thoracic artery with a mean of 2.3 ± 0.9 total grafts. One patient had a BARC-4 bleeding event and there were no surgical re-explorations for bleeding. Mean 24-hours CTD was 680 ± 307mL. During follow-up of 19.5 ± 17.0 months, none of the patients died or required further reinterventions. No device-related adverse events were reported.

CONCLUSIONS

Hemoadsorption via a stand-alone apheresis pump during OPCAB surgery was feasible and safe. This innovative and new approach showed favorable bleeding rates in patients on antithrombotic drugs requiring bypass surgery.

Effective Apixaban removal using hemoadsorption during emergent open-heart surgery: a case report and narrative literature review

BACKGROUND

The management of hemostasis in patients medicated with apixaban (Eliquis) undergoing emergency cardiac surgery is exceedingly difficult. The body's natural elimination pathways for apixaban prove ineffective in emergency situations, and the impact of hemodialysis is limited. The application of Cytosorb® may attenuate the concentration of apixaban, thereby facilitating the stabilization of these patients.

CASE PRESENTATION

An 84-year-old man treated with apixaban, underwent emergency ascending aorta replacement surgery due to an acute type A aortic dissection. To address the challenges induced by apixaban, we integrated Cytosorb® cartridge into the Cardiopulmonary bypass circuit. There was a 63.7% decrease in perioperative apixaban-specific anti-factor Xa activity. The patient's postoperative course was favourable.

CONCLUSION

Hemoadsorption with Cytosorb® may offers a safe and feasible approach for reducing apixaban concentration in emergency cardiac surgery, thereby mitigating the risk of hemorrhagic complications.

Hemoadsorption Therapy for Calcium Channel Blocker Overdose: A Case Report

BACKGROUND

Modern resin hemoadsorption/hemoperfusion for calcium channel blocker overdose is yet to be reported. The characteristics of calcium channel blockers make them unamenable to removal by hemodiafiltration or charcoal hemoperfusion; however, elimination, using styrene bead adsorption in an ex vivo model, has been demonstrated. Its clinical use is described.

CASE REPORT

A man in his 20s was admitted with shock into the Intensive Care Unit (ICU) after an overdose of amlodipine and risperidone. Resuscitation and supportive care were administered, but hypotension did not resolve despite the administration of intravenous fluids, infusions of calcium, adrenaline, and hyperinsulinemic-euglycemic therapy. Methylene blue was then administered to maintain the mean arterial pressures. However, the hemodynamic effect did not allow the weaning of the adrenaline. Drug clearance using hemoadsorption/hemoperfusion was attempted using a styrene resin filter (Jafron HA230; Jafron Biomedical Co., Ltd., Guangdong, China). During the two hemoperfusion sessions (6 h duration each, and 18 h apart) the patient had successfully weaned off all supportive measures, with lactate levels returning to normal and was later discharged home. At the end of each session, significant amlodipine concentrations were detected in blood aspirated from both filters, suggesting enhanced clearance. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case illustrates a temporal relationship between resin hemoperfusion therapy, resolution of hemodynamic instability, and shock without proving causation. Significant amlodipine elimination was suggested by high concentrations found in blood from the filter. At the same time, shock resolution after initiation of hemoperfusion occurred in less than one elimination half-life of amlodipine.

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.

Current clinical practice in using adjunctive extracorporeal blood purification in sepsis and septic shock: results from the ESICM "EXPLORATION" survey

BACKGROUND

Despite a lack of clear evidence extracorporeal blood purification (EBP) is increasingly used as an adjunctive treatment in septic shock based on its biological plausibility. However, current state of praxis and believes in both efficacy and level of evidence are very heterogeneous.

METHODS

The "EXPLORATION" (Current Clinical Practice in using adjunctive extracorporeal blood purification in septic shock), a web-based survey endorsed by the European Society of Intensive Care Medicine (ESICM), questioned both the current local clinical practices as well as future perspectives of EBP in sepsis and septic shock.

RESULTS

One hundred and two people participated in the survey. The majority of three quarters of participants (74.5%) use adjunctive EBP in their clinical routine with a varying frequency of description. Unselective cytokine adsorption (CA) (37.5%) and therapeutic plasma exchange (TPE) (34.1%) were by far the most commonly used modalities. While the overall theoretical rational was found to be moderate to high by the majority of the participants (74%), the effectively existing clinical evidence was acknowledged to be rather low (66%). Although CA was used most frequently in clinical practice, both the best existing clinical evidence endorsing its current use (45%) as well the highest potential to be explored in future clinical trials (51.5%) was attributed to TPE.

CONCLUSIONS

Although the majority of participants use EBP techniques in their clinical practice and acknowledge a subjective good theoretical rationale behind it, the clinical evidence is assessed to be limited. While both CA and TPE are by far the most common used technique, both clinical evidence as well as future potential for further exploration in clinical trials was assessed to be the highest for TPE.

Hemoadsorption Contribution in Failing Fontan Pediatric Heart Transplantation

INTRODUCTION

A systemic inflammatory response is triggered in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). This response is particularly evident in pediatric patients, especially those of low weight and after undergoing long CPB, and can severely impair the surgical result. Adsorptive blood purification techniques have been proposed to limit this systemic inflammatory response. To test its efficacy, we added the hemoadsorption filter Jafron HA 380 to CPB in a much compromised pediatric patient who underwent heart transplantation.

METHODS

A 10-year-old single ventricle patient previously treated with Fontan operation was listed for heart transplantation due to the evidence of failing Fontan condition. He experienced many episodes of cardiac arrest and underwent heart transplantation in much compromised general and hemodynamic conditions. The hemoadsorption filter Jafron HA 380 was used for all the duration of CPB, and the inflammatory biomarker interleukin 6 (IL-6) was assayed.

RESULTS

Postoperative outcome was uneventful and comparable to that of elective pediatric heart transplantation. IL-6 levels showed an impressive postoperative reduction, and after 2 days, the IL-6 level was comparable with a typical uneventful post-transplant course.

CONCLUSIONS

The use of hemoadsorption filter can contribute to improve the pediatric transplant results, especially in very high-risk patients.

Hemoadsorption in acute respiratory distress syndrome patients requiring venovenous extracorporeal membrane oxygenation: a systematic review

BACKGROUND

Venovenous extracorporeal membrane oxygenation (VV ECMO) has been widely used for severe acute respiratory distress syndrome (ARDS) in recent years. However, the role of hemoadsorption in ARDS patients requiring VV ECMO is unclear.

METHODS

Therefore, we conducted a systematic review to describe the effect of hemoadsorption on outcomes of ARDS patients requiring VV ECMO and elucidate the risk factors for adverse outcomes. We conducted and reported a systematic literature review based on the principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The systematic review searched Embase, CINHAL, and Pubmed databases for studies on ARDS patients receiving hemoadsorption and VV ECMO. The demographic data, clinical data and biological data of the patients were collected.

RESULTS

We ultimately included a total of 8 articles including 189 patients. We characterized the population both clinically and biologically. Our review showed most studies described reductions in inflammatory markers and fluid resuscitation drug dosage in ARDS patients with Coronavirus disease 2019 (COVID-19) or sepsis after hemoadsorption.

CONCLUSION

Because most of the studies have the characteristics of high heterogeneity, we could only draw very cautious conclusions that hemoadsorption therapy may enhance hemodynamic stability in ARDS patients with COVID-19 or sepsis receiving VV ECMO support. However, our results do not allow us to draw conclusions that hemoadsorption could reduce inflammation and mortality. Prospective randomized controlled studies with a larger sample size are needed in the future to verify the role of hemoadsorption in ARDS patients requiring VV ECMO.

Hemoadsorption and Coagulation Systemic Rebalance in Patients Undergoing Nonelective Cardiac Surgery and Treated with Antithrombotics

INTRODUCTION

Insufficient withdrawal duration of antithrombotics leads to excessive bleeding after major surgery. We hypothesize that intraoperative hemoadsorption (HA) can reduce postoperative allogeneic transfusion requirements and excessive bleeding events (EBE), without an increase in ischemic/thromboembolic events (ITE) in patients who have taken antithrombotics and undergone nonelective cardiac surgery.

METHODS

A total of 460 patients admitted to our hospital from 2018 to 2022 were included in this study and divided into two groups: HA and non-HA. Because of the risk of bias due to differences in antithrombotic type, withdrawal duration, or basic coagulation function, propensity score matching was used for analyses.

RESULTS

Out of 154 cases in the HA group, 144 pairs were successfully matched. No HA safety events such as hemolysis, hypotension, or device failure occurred. After matching, the two groups were found to be comparable in preoperative antithrombotic type, withdrawal duration, platelets and coagulation function, and demographic and perioperative characteristics. Although the HA group did not have a reduced incidence of EBE, this group exhibited significant decreases in the transfusion rate and volume, the incidence of ITE, acute kidney injury, and central nervous system injury.

CONCLUSIONS

For patients who have undergone nonelective cardiac surgery and taken antithrombotics, HA can simply and safely rebalance the postoperative coagulation system and have associations with reduced transfusion and postoperative ITE.

Nomenclature of Extracorporeal Blood Purification Therapies for Acute Indications: The Nomenclature Standardization Conference

The development of new extracorporeal blood purification (EBP) techniques has led to increased application in clinical practice but also inconsistencies in nomenclature and misunderstanding. In November 2022, an international consensus conference was held to establish consensus on the terminology of EBP therapies. It was agreed to define EBP therapies as techniques that use an extracorporeal circuit to remove and/or modulate circulating substances to achieve physiological homeostasis, including support of the function of specific organs and/or detoxification. Specific acute EBP techniques include renal replacement therapy, isolated ultrafiltration, hemoadsorption, and plasma therapies, all of which can be applied in isolation and combination. This paper summarizes the proposed nomenclature of EBP therapies and serves as a framework for clinical practice and future research.

Effects of Blood Hemoadsorption Therapy with HA-380 in Total Arch Replacement for Acute Type A Aortic Dissection: A Retrospective Observational Study

INTRODUCTION

This study aimed to evaluate whether the addition of a hemoadsorption (HA) cartridge, HA-380, in the cardiopulmonary bypass (CPB) circuit in acute type A aortic dissection (ATAAD) surgery reduced inflammatory cytokine levels and decreased postoperative complications.

METHODS

A retrospective observational cohort study was conducted between March 1, 2021, and February 28, 2022. Patients with ATAAD undergoing emergent total arch replacement surgery were divided into the control (CON) and HA groups on the basis of the addition of the HA-380 cartridge in the CPB circuit.

RESULTS

Overall, 121 patients met the eligibility criteria; 2 patients in each group who died within the first postoperative week were excluded. Further, 57 and 60 patients in the CON and HA groups, respectively, were included in the pooled analysis. The major perioperative data, baseline values of interleukin-6 (IL-6) and C-reactive protein, and therapeutic interventions were similar in the two groups (all, p > 0.05). The serum IL-6 levels increased more rapidly in the CON group than those in the HA group postoperatively (205.73 ± 174.72 vs. 146.13 ± 64.15 pg/mL, p = 0.020). The HA group had a lower incidence of postoperative acute kidney injury (AKI) and severe acute respiratory distress syndrome than the CON group (25.4 vs. 44.6%, p = 0.032 and 18.3 vs. 35.1%, p = 0.040, respectively). Logistic regression analyses showed that HA may be a protective factor against postoperative AKI. The incidence of bleeding, delirium, and stroke as well as the lengths of intensive care unit and hospital stay in both groups were similar (all, p > 0.05).

CONCLUSIONS

The use of HA-380 in the CPB circuit may attenuate inflammatory response and reduce major complications following ATAAD surgery. HA may be associated with lower rate of postoperative AKI.

Vancomycin and Gentamicin Removal with the HA380 Cartridge during Experimental Hemoadsorption

INTRODUCTION

Hemoadsorption has emerged as an adjunctive therapy for sepsis, but its impact on antibiotic levels remains poorly defined. We conducted an in vivo experimental study to investigate the removal of vancomycin and gentamicin during hemoadsorption using the HA380 cartridge, a novel styrene-divinylbenzene copolymer cartridge.

METHODS

Six surgically prepared sheep were administered 2 g of vancomycin and 400 mg of gentamicin over 30 min, followed by a continuous infusion of vancomycin (20 mg/h). Hemoadsorption was implemented with a styrene-divinylbenzene copolymer HA380 cartridge at a blood flow of 120 mL/min. The removal ratio, sorbent-based clearance, and the mass removal rate were calculated for each time point.

RESULTS

The mean 10-min vancomycin removal ratio exceeded 90% and declined to 68.0% at 30 min; 52.8% at 60 min, and 28.0% by 4 h. Due to constant plasma flow, clearance varied proportionally with the removal ratio. Over 4 hours, the total mass removal was 556 mg (SD 106.3). For gentamicin, the mean 10-min removal ratio was 96.9% and the final ratio at 4 h remained 53.0%, with clearances changing proportionately. The total mass removal of gentamicin was 138 mg (SD 26.6) over 4 h. The sorbent-based clearance of vancomycin was significantly lower than that of gentamicin (Pgroup < 0.0001).

CONCLUSION

The novel HA380 sorbent cartridge appears safe and achieves significant vancomycin and gentamicin removal over a four-hour period. This information can be used by clinicians to guide their prescription and consider the additional dosing of at least an extra 25-35% amount in patients receiving HA380 hemoadsorption therapy during sepsis.

Extracorporeal hemoadsorption therapy as a potential therapeutic option for rapid removal of Apixaban in high risk-surgical patients: a case report

BACKGROUND

Apixaban is a non-vitamin K antagonist oral anticoagulant (NOACs) recently emerged as an effective alternative to conventional vitamin K antagonists (VKAs) in the treatment of several thromboembolic disorders. However, in case of overdose or in patients requiring emergency surgery there is a high bleeding rate and severe adverse side effects due to the absence of an antidote. There is promising data from in vitro and clinical studies, that certain antithrombotic agents (that is Rivaroxaban and Ticagrelor) have been successfully removed by the extracorporeal hemoadsorption therapy CytoSorb. Here, we present the case of a patient successfully treated with CytoSorb as a kind of antidote to enable emergency surgery for bilateral nephrostomy.

CASE PRESENTATION

A 82-year-old Caucasian man was admitted to the Emergency Room with acute kidney injury (AKI) in the context of severe bilateral hydroureteronephrosis. The patient's medical history included chronic obstructive pulmonary disease, arterial hypertension, atrial fibrillation (anticoagulated with Apixaban) and a locally advanced prostate adenocarcinoma treated with trans-ureteral resection of the bladder and radiotherapy in the previous months. The indication for a bilateral nephrostomy could not be considered immediately given the major bleeding risk due to Apixaban, which was discontinued and replaced with calciparin. After 36 hours of continuous renal replacement therapy (CRRT), the Apixaban blood level was still elevated and it was decided to install CytoSorb into the running CRRT to accelerate the drug clearance. After 2 hours 30 minutes, there was good reduction of Apixaban from 139 to 72 ng/ml (reduction rate of 48.2%) registered, and this allowed for an easy placement of bilateral nephrostomies without complications. Four days after surgery renal function parameters further normalized, the patient did not require additional dialysis treatments and Apixaban therapy was prescribed again once the patient returned home.

CONCLUSIONS

In this case we report the findings of a patient with post-renal AKI requiring emergency nephrostomy placement while on chronic anticoagulation with Apixaban therapy. Combined treatment with CRRT and CytoSorb was associated with the rapid and effective removal of Apixaban allowing for prompt and urgent surgery while simultaneously ensuring the low risk of bleeding as well as an uneventful post-operative course.

Extracorporeal hemoadsorption in critically ill COVID-19 patients on VV ECMO: the CytoSorb therapy in COVID-19 (CTC) registry

OBJECTIVES

The CytoSorb therapy in COVID-19 (CTC) registry evaluated the clinical performance and treatment parameters of extracorporeal hemoadsorption integrated with veno-venous extracorporeal membrane oxygenation (VV ECMO) in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) and respiratory failure under US FDA Emergency Use Authorization.

DESIGN

Multicenter, observational, registry (NCT04391920).

SETTING

Intensive care units (ICUs) in five major US academic centers between April 2020 and January 2022.

PATIENTS

A total of 100 critically ill adults with COVID-19-related ARDS requiring VV ECMO support, who were treated with extracorporeal hemoadsorption.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline demographics, clinical characteristics, laboratory values and outcomes were recorded following individual ethics committee approval at each center. Detailed data on organ support utilization parameters and hemoadsorption treatments were also collected. Biomarker data were collected according to the standard practice at each participating site, and available values were compared before and after hemoadsorption. The primary outcome of mortality was evaluated using a time-to-event analysis. A total of 100 patients (63% male; age 44 ± 11 years) were included. Survival rates were 86% at 30 days and 74% at 90 days. Median time from ICU admission to the initiation of hemoadsorption was 87 h and was used to define two post hoc groups: ≤ 87 h (group-early start, GE) and > 87 h (group-late start, GL). After the start of hemoadsorption, patients in the GE versus GL had significantly shorter median duration of mechanical ventilation (7 [2-26] vs. 17 [7-37] days, p = 0.02), ECMO support (13 [8-24] vs. 29 [14-38] days, p = 0.021) and ICU stay (17 [10-40] vs 36 [19-55] days, p = 0.002). Survival at 90 days in GE was 82% compared to 66% in GL (p = 0.14). No device-related adverse events were reported.

CONCLUSIONS

In critically ill patients with severe COVID-19-related ARDS treated with the combination of VV-ECMO and hemoadsorption, 90-day survival was 74% and earlier intervention was associated with shorter need for organ support and ICU stay. These results lend support to the concept of "enhanced lung rest" with the combined use of VV-ECMO plus hemoadsorption in patients with ARDS.

Adjunctive hemoperfusion with Resin Hemoadsorption (HA) 330 cartridges improves outcomes in patients sustaining multiple Blunt Trauma: a prospective, quasi-experimental study

BACKGROUND

Multi-organ dysfunction syndrome and multi-organ failure are the leading causes of late death in patients sustaining severe blunt trauma. So far, there is no established protocol to mitigate these sequelae. This study assessed the effect of hemoperfusion using resin-hemoadsorption 330 (HA330) cartridges on mortality and complications such as acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) among such patients.

METHODS

This quasi-experimental study recruited patients ≥ 15 years of age with blunt trauma, injury severity score (ISS) ≥ 15, or initial clinical presentation consistent with SIRS. They were divided into two groups: the Control group received only conventional acute care, while the case group received adjunctive hemoperfusion. P-values less than 0.05 were statistically significant.

RESULTS

Twenty-five patients were included (Control and Case groups: 13 and 12 patients). The presenting vital signs, demographic and injury-related features (except for thoracic injury severity) were similar (p > 0.05). The Case group experienced significantly more severe thoracic injuries than the Control group (Thoracic AIS, median [IQR]: 3 [2-4] vs. 2 [0-2], p = 0.01). Eleven and twelve patients in the Case group had ARDS and SIRS before the hemoperfusion, respectively, and these complications were decreased considerably after hemoperfusion. Meanwhile, the frequency of ARDS and SIRS did not decrease in the Control group. Hemoperfusion significantly reduced the mortality rate in the Case group compared to the Control group (three vs. nine patients, p = 0.027).

CONCLUSIONS

Adjunctive Hemoperfusion using an HA330 cartridge decreases morbidity and improves outcomes in patients suffering from severe blunt trauma.

CytoSorb hemoperfusion markedly attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo

BACKGROUND

The CytoSorb hemoadsorption device has been demonstrated to be capable of clearing inflammatory cytokines, but has not yet been shown to attenuate plasma cytokine concentrations. We investigated the effects of CytoSorb hemoperfusion on plasma levels of various cytokines using the repeated human experimental endotoxemia model, a highly standardized and reproducible human in vivo model of systemic inflammation and immunological tolerance induced by administration of bacterial lipopolysaccharide (LPS).

METHODS

Twenty-four healthy male volunteers (age 18-35) were intravenously challenged with LPS (a bolus of 1 ng/kg followed by continuous infusion of 0.5 ng/kg/hr for three hours) twice: on day 0 to quantify the initial cytokine response and on day 7 to quantify the degree of endotoxin tolerance. Subjects either received CytoSorb hemoperfusion during the first LPS challenge (CytoSorb group), or no intervention (control group). Plasma cytokine concentrations and clearance rates were determined serially. This study was registered at ClinicalTrials.gov (NCT04643639, date of registration November 24th 2020).

RESULTS

LPS administration led to a profound increase in plasma cytokine concentrations during both LPS challenge days. Compared to the control group, significantly lower plasma levels of tumor necrosis factor (TNF, - 58%, p < 0.0001), interleukin (IL)-6 ( - 71%, p = 0.003), IL-8 ( - 48%, p = 0.02) and IL-10 ( - 26%, p = 0.03) were observed in the CytoSorb group during the first LPS challenge. No differences in cytokine responses were observed during the second LPS challenge.

CONCLUSIONS

CytoSorb hemoperfusion effectively attenuates circulating cytokine concentrations during systemic inflammation in humans in vivo, whereas it does not affect long-term immune function. Therefore, CytoSorb therapy may be of benefit in conditions characterized by excessive cytokine release.

Severe Clozapine Poisoning Treated by Extracorporeal Blood Purification Therapy

Clozapine is a frequently used antipsychotic that, in case of overdose, can cause severe adverse side effects, such as hematological, cardiovascular, and neurological complications. As there is no specific antidote or reversal agent available, extracorporeal techniques such as CytoSorb hemoadsorption might represent a viable option, having already been used in a variety of intoxication scenarios with favorable rates of success. A 56-year-old male was admitted with generalized epileptic seizures and arrhythmias following ingestion of clozapine in a suicide attempt (5,000 mg). Subsequently, conventional supportive care was initiated. To accelerate drug removal, continuous veno-venous hemodiafiltration including the application of CytoSorb hemoadsorption therapy was started. Serial measurements confirmed rapid reduction of clozapine plasma levels. The patient remained hemodynamically stable throughout this period. Furthermore, there were no cardiac arrhythmias detected and liver values were normal. The patient improved and was successfully extubated 3 days after admission with good vigilance and no residual neurological abnormalities. This is the first clinical case report on the use of CytoSorb hemoadsorption in severe clozapine intoxication which helped quickly and efficiently reduce clozapine levels to nontoxic serum levels while preserving organ function. Therefore, CytoSorb might represent an alternative treatment modality to be considered for potentially lethal clozapine intoxications.

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.

Vancomycin Adsorption during in vitro Model of Hemoperfusion with Mini-Module of HA380 Cartridge

INTRODUCTION

Sepsis is a frequent complication in critically ill patients. Patients may require control of the source of infection, removal of pathogens and damaged cells, and organ support. Often, these targets can be achieved through the utilization of extracorporeal therapies including hemoperfusion for the adsorption of cytokines and other circulating mediators. On extracorporeal organ support, patients are generally treated with antibiotic therapy, and vancomycin is one of the most commonly used antibiotics. Because of the aspecific nature of adsorption, antibiotics can be removed from the circulation, leading to altered plasma levels and requiring prescription adjustment. The aim was to define the amount of vancomycin adsorbed by a sorbent cartridge (HA380, Jafron, China) during hemoperfusion and to establish possible strategies to maintain an effective plasma level in critically ill patients undergoing extracorporeal therapies.

METHODS

In vitro experiments with incremental concentrations of vancomycin in the test solution (500 and 1,000 mL) were carried out in a recirculation circuit until sorbent saturation was observed. A maximum of 10 g of vancomycin were injected and mini-modules containing 25 g of dry resin were utilized.

RESULTS

In different experiments with various concentration of vancomycin, a maximum amount of 244 mg/g of sorbent was adsorbed reaching saturation between 60 and 80 min from the beginning of the experiments. The kinetics of adsorption appears to be governed by a Langmuir-like isotherm with maximal removal speed in the early minutes and a plateau after 60 min.

DISCUSSION/CONCLUSION

HA380 adsorbs significant amounts of vancomycin. Adjusting the achieved results with the experimental mini-module to a full-scale cartridge, a total of 25 g of antibiotic can be removed. This might have affected outcome results in clinical trials. This suggests prescribing administration to critically ill patients requiring hemoperfusion, immediately after or in the inter-session time window. In case of administration during hemoperfusion, adequate adjustment and plasma level monitoring is strongly recommended.

Use of CytoSorb® hemoadsorption column during prolonged cardiopulmonary bypass in complex cardiac surgery patient

Background

Complex cardiac surgery and prolonged cardiopulmonary bypass are associated with significant activation of the systemic inflammatory response system. Pro-inflammatory cytokines, oxygen free radicals and complement activation products contribute to postoperative complications and multiorgan injury. CytoSorb® hemoadsorption therapy has been suggested to alleviate the hyperinflammatory response triggered by cardiopulmonary bypass during cardiac surgery.

Case presentation

We describe the use of CytoSorb® hemoadsorption therapy in a 61-year-old male presenting for aortic valve replacement, mitral valve replacement, tricuspid valve repair, coronary artery bypass grafting and left atrial appendage clip.

Conclusion

We were able to demonstrate that CytoSorb® use during cardiopulmonary bypass may be a safe and feasible adjunct therapy that may contribute to improved postoperative outcomes in a patient with complex cardiac disease.

Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

Background

The effects and safety of extracorporeal hemoadsorption with CytoSorb® in critically ill patients with inflammatory conditions are controversial.

Methods

We performed a systematic review with meta‐analysis and trial sequential analysis (TSA) of randomized‐controlled trials to assess the mortality and safety of CytoSorb® therapy in critically ill patients with inflammatory conditions. Electronic databases were searched up to April 2022. The primary outcome was mortality at longest follow‐up and secondary outcomes included various adverse event (AE) outcomes. Conflict of interest and funding of each trial were assessed. We calculated relative risk (RR) and 95% confidence interval (CI).

Results

Fourteen published (n = 764) and 4 unpublished (n = 111) trials were included. Eight trials were performed in medical ICU patients and 10 in complex cardiac surgery. Ten trials had significant industrial funding or an author conflict of interest. Hemoadsorption with CytoSorb® was associated with higher mortality at latest follow‐up (16 trials, n = 807, 120 of 402 [29.85%] patients in the CytoSorb® group vs. 98 of 405 [24.20%] patients in the control group, RR = 1.24 [95% CI, 1.04–1.49], p = .02, [TSA‐adjusted CI, 0.92–1.68]) and at 30‐days or in‐hospital (11 trials, n = 727; RR = 1.41 [95% CI, 1.06–1.88], p = .02, [TSA‐adjusted CI, 0.44–4.62]). Only one trial reported the definition of adverse event, while detailed results were reported in 3 trials; the risk of adverse events was not higher with CytoSorb®. Certainty of evidence ranged from low to very low.

Conclusion

Low certainty of evidence showed that the use of CytoSorb® might increase mortality in critically ill patients with inflammatory conditions. Adverse events were frequent but underreported and not systematically evaluated. Industrial funding and conflict of interest were common. Considerable uncertainty about the findings does not allow firm conclusions and suggests a need for high‐quality randomized trials to clarify mortality and adverse events related to CytoSorb®.

Editorial Comment

Hemoadsorption with CytoSorb® have been used in critically ill patients despite lack of high quality data from RCTs suggesting any patient‐important benefits. The findings from this systematic review and meta‐analysis suggests an increased risk of adverse events including mortality. With no apparent benefits and at the same time risk of harm, use of hemoadsorption with CytoSorb® in daily clinical practice cannot be recommended at this time.

Efficacy of HA330-II column hemoadsorption in Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis combined with liver failure: A case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a severe and potentially deadly condition associated with extensive inflammation and immune activation. Cytokine adsorption may serve as a supportive treatment that can stabilize organ function in affected patients by reducing their circulating cytokines levels. To date, no descriptions of clinical experiences associated with the use of HA330-II column hemoadsorption for the treatment of children affected by HLH have been published.

CASE SUMMARY

We describe the case of an 11-year-old child with Epstein-Barr virus-associated HLH complicated by liver failure. She underwent HA330-II column hemoadsorption and chemotherapy and exhibited reductions in levels of inflammatory cytokines, including interleukin (IL), IL-6, IL-8, IL-10, and interferon-γ. The patient’s condition and laboratory parameters gradually improved with treatment.

CONCLUSION

Hemoadsorption may play an important role in cytokine storm elimination in children with HLH combined with liver failure and consequent multiple organ failure.

Single-pass albumin dialysis and hemoadsorption for bilirubin and bile acids removal for a child with hyperbilirubinemia after ventricular assist device implantation

We report the successful management of hyperbilirubinemia using two different modalities of extracorporeal bilirubin removal therapy for a pediatric patient. A 13-year-old boy with dilated cardiomyopathy requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) developed acute kidney injury and was dependent on continuous renal replacement therapy. He developed hyperbilirubinemia with a peak total bilirubin level of 786 μmol/L after implantation of biventricular assist device (BiVAD). Extracorporeal bilirubin and bile acids removal using single-pass albumin dialysis (SPAD) with 4% albumin as dialysate brought down the bilirubin level to 672 μmol/L after 21 h of therapy. Subsequently, he was started on two sessions of hemoadsorption using the Cytosorb® column which further lowered the total bilirubin level to 306 μmol/ in 24 h and 173 μmol/ after the treatment. No complication was encountered. Our case illustrated that both SPAD and hemoadsorption can effectively and safely reduce the serum bilirubin and bile acid levels in pediatric patients with BiVAD implantation. The ease of set-up, faster rate of bilirubin decline and capability of cytokine removal make hemoadsorption a favorable alternative to albumin dialysis.

Observational case series: six neurosurgical patients with septic shock demonstrating clinical improvement after a combination of standard care and blood purification

Background

For patients with primary brain injury, septic shock is especially dangerous due to the possibility of secondary cerebral damage. The key factor of sepsis-associated brain injury is inflammatory mediators, pathogen and damage-associated molecular patterns (PAMPs, DAMPs) release. Theoretically, blood purification may be beneficial for patients with primary brain injury due to its possibility for fast removal of inflammatory mediators.

Case presentation

We report on six post-neurosurgery septic shock patients treated with combined blood purification (CBP), which included CRRT with high adsorption capacity membrane in combination with CytoSorb adsorber. Clinical improvement in the course of CBP was registered in all patients. Three patients had a stable clinical improvement; the other three patients had only a transient improvement due to underlying neurological and cardiac deficits aggravation. We observed septic shock reversal in four patients. The key observations of the case series are a significant decrease in MOF severity (measured by SOFA score) and in catecholamine need (not statistically significant). By the end of CBP we observed a significant decrease in blood lactate, PCT and IL-6 levels. Two patients demonstrated level of consciousness increase in the setting of CBP therapy measured by GCS and FOUR score.

Conclusion

This case series demonstrates that CBP therapy may have a role for septic shock patients with primary brain injury.

Cytokine Adsorption Therapy during Extracorporeal Membrane Oxygenation in Adult Patients with COVID-19

Respiratory failure and systemic inflammation are paramount features of severe SARS-CoV-2 disease (COVID-19). Extracorporeal membrane oxygenation (ECMO) therapy has a potential role in patients with refractory disease. An inflammatory response due to blood contact with hemofilters, functioning as a synergic inflammatory stimulus, can lead to a hyperinflammatory state, relatable to cytokine release syndromes. After the first patient succumbed to a refractory vasodilatory shock believed to be due to hyperinflammatory state, a strategy of blood purification through cytokine adsorption therapy (CAT) with CytoSorb® was designed. In this case series, the authors describe the initial experience with such strategy. CAT was employed with no direct complications and helped controlling the inflammatory state, with all patients halting vasopressor support in 72 h and biomarker levels (C-reactive protein, ferritin, and interleukin-6) showing negative trends in most patients. Analysis of inflammatory biomarkers evolution highlighted 2 biomarker profiles related to the presence or absence of superinfection at the time of CAT implementation. In this case series of severe COVID-19 patients, 3 patients died − irreversible lung fibrosis, complications of critical hypoxemia before ECMO induction and complications of systemic anticoagulation were the causes. This case series aimed to contribute to the body of evidence substantiating CAT utilization in hyperinflammatory patients, namely, COVID-19 patients requiring ECMO rescue.

Successful Treatment of Severe Lamotrigine Intoxication with CytoSorb Hemoadsorption

Severe intoxication with the anti-epileptic drug, lamotrigine can cause cardiovascular collapse, neurotoxicity - expressed as intractable seizures, and even death. As there is currently no known specific antidote, extracorporeal removal therapies such as CytoSorb hemoadsorption might represent a promising therapeutic option. We report on a deeply comatosed 60-year-old woman who was treated in our intensive care unit with severe lamotrigine intoxication. To support removal from the blood, combined treatment with continuous veno-venous hemodialysis and CytoSorb hemoadsorption was started. Pre- and post-adsorber drug level measurements showed the rapid elimination of lamotrigine accompanied by an impressive clinical improvement in the patient. Two days after treatment discontinuation, there were no more clinical signs of intoxication and the patient could be extubated, followed by transfer to the stroke unit in a stable condition the following day. In the absence of a viable antidote, for the efficient short-term removal of lamotrigine, hemoadsorption with the CytoSorb device could represent a feasible treatment option for patients with severe lamotrigine intoxication.

Successful use of CytoSorb in a Covid-19 patient with secondary septic shock due to a sacral decubitus infection

Septic shock is a clinical condition with high mortality (40%-70%) and morbidity. During septic shock, there is a significant release of cytokines and other inflammatory mediators that can cause damage to different organs, known as a "cytokine storm." The cytokine storm can cause hypotension, tissue damage, metabolic acidosis, and renal failure. This clinical picture also seems to be confirmed in the context of Covid-19 patients. Hemoadsorption with CytoSorb represents an adjunctive therapy to attenuate the systemic inflammatory process and helps restore a balanced immune response. We present the clinical case of a 75-year-old man, admitted to our hospital with respiratory failure due to Sars-CoV-2 infection and secondary septic shock due to a sacral decubitus. On admission the patient presented with a clinical picture of mixed acidosis with high levels of lactate and inflammatory indexes. Simultaneously along with antibiotic therapy, we started hemoadsorption treatment with CytoSorb in combination with continuous venous-venous hemodiafiltration. At the end of the treatment the patient had recovered his vital functions and the infection was successfully treated. Use of the CytoSorb device in a Covid-19 positive patient was safe and well-tolerated. Early treatment with CytoSorb decreased interleukin 6 plasma levels and inflammatory indexes, resulting in earlier stabilization of homeostasis. This case report suggests that the use of CytoSorb could be a possible adjuvant therapy in patients with septic shock even when affected by Covid-19.

The effect of hemoadsorption on rivaroxaban blood plasma concentration in emergency cardiac surgery

Hemoadsorption was used in a 59-year-old patient with an acute type A aortic dissection, who was on rivaroxaban and dual antiplatelet therapy with clopidogrel and acetylsalicylic acid. Our aim was to expeditiously remove rivaroxaban preoperatively. After 8 h of hemoadsorption, the rivaroxaban blood plasma concentration (RBPC) did not decrease below 42.1 μg/l. Intraoperatively, hemoadsorption was repeated during extracorporeal circulation. Sixteen hours after surgery and a total of 13 h of hemoadsorption, the RBPC was 40.1 μg/l. Thereafter, the RBPC spontaneously decreased to 24.7 μg/l within 14 h. In our patient, hemoadsorption may have enhanced rivaroxaban removal at higher RBPC (cutoff value 40–50 μg/l). At lower RBPC, the removal of rivaroxaban may depend solely on the natural drug elimination process. The evolution of the RBPC under hemoadsorption in vivo warrants a thorough investigation. Further clinical studies are required to assess the effectiveness and limitations of hemoadsorption to preclude a fatal bleeding event in patients with rivaroxaban in need of major emergency surgery.

High-dose CytoSorb hemoadsorption is associated with improved survival in patients with septic shock: A retrospective cohort study

BACKGROUND AND PURPOSE

Hemoadsorption with CytoSorb® offers a possible therapeutic approach in septic shock, but modes of application and dosing are still undetermined.

MATERIALS AND METHODS

Data from surgical patients with septic shock, treated with hemoadsorption adjunctive to renal replacement therapy were analyzed retrospectively. The 28-day mortality was compared to predicted mortality.

RESULTS

In 70 patients (70.6 ± 13.3 years), hemoadsorption was applied for 85.6 ± 53.8 h. The APACHE ll (30.2 ± 6.3) calculated to a predicted mortality of 73.3%, while the observed mortality was significantly lower (50%, p < 0.05). The amount of blood purified was higher in survivors than in non-survivors (8.5 ± 4.4 vs. 6.1 ± 3.6 l/kgBW, p = 0.017). We identified three clusters of <6 l/kgBW, 6-13 l/kgBW and ≥ 13 l/kgBW with a linear dose-response relation between blood purification volume and survival, which was best in the highest volume cluster (83.3%; p = 0.045).

CONCLUSIONS

The application of CytoSorb® seems to be effective in various conditions of septic shock. In a cohort of most severely ill patients the observed mortality was lower than predicted and decreased linearly with blood purification volumes inadvertently exceeding 6 l/kg BW. These results suggest that hemoadsorption might improve survival provided that the applied dose is high enough.

New Therapeutic Approach to Reduce Methotrexate Toxicity after High-Dose Chemotherapy in a Child with Acute Lymphocytic Leukemia: Efficacy and Safety of Hemoadsorption with HA-230 Adsorber

BACKGROUND

High-dose methotrexate (HDMTX) is likely to cause a number of side effects and manifest itself as hepatotoxicity, nephrotoxicity, mucositis, and neurotoxicity. A several studies demonstrated the efficacy of extracorporeal detoxification methods such as plasma exchange, hemodialysis (HD), HD filtration, and hemoperfusion for the treatment of MTX delayed clearance. However, none of the existing methods as effective as expected and limited for general implementation due to a procedure-related complication.

CASE REPORT

Here, we report a successful implementation of HA-230 hemoadsorption procedure to remove cumulated MTX from the body and reduce its toxicity in a child with ALL after high-dose chemotherapy.

RESULTS AND CONCLUSION

Based on our results, single-hemoadsorption procedure with the HA-230 adsorber in case of delayed methotrexate clearance was safe and well-tolerated in a pediatric patient with ALL and would significantly improve the patient's condition. Further studies need to demonstrate its safety and efficacy in a large number of pediatric patients.

Hemoadsorption to treat severe iatrogenic intoxication with Patent Blue: a case report

Background

Intoxication with Patent Blue V [sodium compound of (diethylamino-4-phenyl)(hydroxy-5-disulfo-2,4-phenyl) methanol] can lead to high levels of methemoglobin and metabolic acidosis. In severe cases and if not rapidly eliminated from the plasma, this can lead to multiple organ failure and death.

Case report

A 27-year-old Asian woman (original from Vietnam) was admitted after ecstasy intoxication resulting in multi-organ failure (acute respiratory distress syndrome, metabolic acidosis, capillary leakage syndrome, renal failure, shock refractory to standard resuscitation). As a consequence, continuous renal replacement therapy and veno-venous extracorporeal membrane oxygenation were started. Methylene blue administration to reverse vasoplegia was decided, but unfortunately, Patent Blue V was erroneously administered, resulting in a severe clinical picture of methemoglobinemia and tissue hypoxia. As a therapeutic intervention, CytoSorb hemoadsorption was initiated, and rapid and significant reduction in plasma methemoglobin, accompanied by improved hemodynamics and normalization in plasma lactate levels, was observed.

Conclusions

This is the first case describing the application of CytoSorb hemoadsorption in a patient with ecstasy intoxication complicated by iatrogenic administration of Patent Blue V. There is a potential role for CytoSorb in drug intoxication, which needs to be confirmed in larger series.

Successful Treatment of Severe Digitoxin Intoxication with CytoSorb® Hemoadsorption

While several intoxications can be successfully treated with specific antidotes, intoxications with the steroid glycoside digitoxin still represent a major challenge. Besides conventional approaches, CytoSorb® hemoadsorption might be another treatment option. We report on an 81-year-old female patient treated in our intensive care unit (ICU) with severe digitoxin intoxication, acute renal failure, and urinary tract infection (UTI). As physiological digitoxin elimination kinetics are known to appear slow, and also in regard to the renal failure, the decision was made to initiate continuous renal replacement therapy combined with CytoSorb hemoadsorption. The patient was hemodynamically stabilized within the first 4 h of treatment and initially required catecholamines to be stopped within 24 h of treatment. Pre- and post-adsorber drug level measurements showed a rapid elimination of digitoxin. Antibiotic treatment with piperacillin/tazobactam was initiated, and despite CytoSorb hemoadsorption therapy and its known potential to reduce plasma concentrations of several drugs, the UTI was successfully treated. After 3 days of CytoSorb treatment, digitoxin plasma levels were stable and almost normalized, and no clinical signs of intoxication were present. Five days after presentation, the patient was transferred from the ICU in a stable condition. CytoSorb hemoadsorption may be an easily available, efficient, and less cost-intensive therapy option than treatment with the Fab fragment, which is the currently recommended therapy for digitalis intoxications. Therefore, the use of CytoSorb might represent an alternative treatment for life-threatening complications of digitoxin intoxications.

Rationale for Medium Cutoff Membranes in COVID-19 Patients Requiring Renal Replacement Therapy

The current pandemic of coronavirus disease 2019 (COVID-19) spotlighted the vulnerability of patients with chronic kidney disease stage 5 on maintenance hemodialysis (HD) to the viral infection. Social distancing is the most effective preventive measure to reduce the risk of infection. Nonetheless, the necessity to frequently reach the dialysis center and the inherent social gathering both impede social distancing and also self-quarantine for infected individuals. A baseline hyperinflammatory state driven by factors such as the retention of uremic toxins afflicts these patients. Concomitantly, a condition of relative immunosuppression is also attributed to similar factors. The use of high-flux (HF) dialyzers for HD is the standard of care. However, with HF membranes, the removal of large middle molecules is scant. Medium cutoff (MCO) dialyzers are a new class of membranes that allow substantial removal of large middle molecules with negligible albumin losses. Recent trials confirmed long-term safety and long-term sustained reduction in the concentration of large uremic toxins with MCO dialyzers. Herein, we discuss the rationale for applying MCO membranes in COVID-19 patients and its possible immunoadjuvant effects that could mitigate the burden of COVID-19 infection in dialysis patients. We also discuss the direct cytopathic effect of the virus on renal tissue and extracorporeal blood purification techniques that can prevent kidney damage or reduce acute kidney injury progression.

[Hemoadsorption for blood purification-incomparability of clinically available procedures]

Hintergrund

Im Bereich der Intensivmedizin, aber auch verstärkt in der Herzchirurgie, gewinnt der Einsatz von adsorptiven Blutreinigungstechnologien zur Behandlung von hyperinflammatorischen Zuständen an Bedeutung. Neben dem CytoSorb-Verfahren, das zunehmend klinisch akzeptiert und auch aktuell am häufigsten eingesetzt wird, drängen seit Kurzem weitere Firmen – vor allem aus China – mit ähnlichen Konzepten auf den Markt.

Ziel der Arbeit

Vor diesem Hintergrund soll es Ziel dieses Artikels sein, exemplarisch auf unterschiedliche Aspekte zwischen den am Markt angebotenen Hämoadsorptionsprodukten einzugehen und einen kritischen Blick auf die vorhandene Evidenz zu werfen.

Methoden

Analysiert wurden technische Merkmale, applikationsspezifische Besonderheiten und vorhandene Evidenz der Adsorptionstechnologien CytoSorb® (CytoSorbents^TM Inc., Monmouth Junction, NJ, USA), Jafron® HA-Serie (Jafron Biomedical Co., Guangdong, China) sowie der Biosky® MG-Serie (Biosun® Medical Technology Co., Foshan City, Guangdong Province, China). Nicht einbezogen wurden rein substanzspezifische Verfahren zur Endotoxinelimination (Toraymyxin®, Alteco®).

Ergebnisse

Bei umfassender Analyse dieser Kriterien zeigt sich, dass zwischen den verfügbaren Technologien erhebliche Unterschiede hinsichtlich verwendeter Materialien, Adsorptionscharakteristika, Anwendung und verfügbarer Daten zu Sicherheit und klinischer Erfahrungen bestehen. Darüber hinaus wird deutlich, dass bei Blutreinigungstechnologien nicht nur deren Wirksamkeit unter Berücksichtigung eines Effekt-Preis-Leistungs-Verhältnisses betrachtet werden sollte, sondern insbesondere auch die klinische Sicherheit der einzelnen Verfahren von entscheidender Bedeutung ist.

Diskussion

Unter den analysierten Technologien stellt unserer Ansicht nach derzeit CytoSorb das am besten untersuchte und klinisch am weitesten etablierte Verfahren dar. Darüber hinaus ist darauf hinzuweisen, dass klinische Ergebnisse, insbesondere jedoch auch sicherheitsrelevante Aspekte, aufgrund der technisch unterschiedlichen Verfahren nicht zwischen den Produkten übertragbar sind.

Extracorporeal Blood Purification and Organ Support in the Critically Ill Patient during COVID-19 Pandemic: Expert Review and Recommendation

Critically ill COVID-19 patients are generally admitted to the ICU for respiratory insufficiency which can evolve into a multiple-organ dysfunction syndrome requiring extracorporeal organ support. Ongoing advances in technology and science and progress in information technology support the development of integrated multi-organ support platforms for personalized treatment according to the changing needs of the patient. Based on pathophysiological derangements observed in COVID-19 patients, a rationale emerges for sequential extracorporeal therapies designed to remove inflammatory mediators and support different organ systems. In the absence of vaccines or direct therapy for COVID-19, extracorporeal therapies could represent an option to prevent organ failure and improve survival. The enormous demand in care for COVID-19 patients requires an immediate response from the scientific community. Thus, a detailed review of the available technology is provided by experts followed by a series of recommendation based on current experience and opinions, while waiting for generation of robust evidence from trials.

Influence of hemoadsorption during cardiopulmonary bypass on blood vesicle count and function

Background

Extracorporeal circulation during major cardiac surgery triggers a systemic inflammatory response affecting the clinical course and outcome. Recently, extracellular vesicle (EV) research has shed light onto a novel cellular communication network during inflammation. Hemoadsorption (HA) systems have shown divergent results in modulating the systemic inflammatory response during cardiopulmonary bypass (CPB) surgery. To date, the effect of HA on circulating microvesicles (MVs) in patients undergoing CPB surgery is unknown.

Methods

Count and function of MVs, as part of the extracellular vesicle fraction, were assessed in a subcohort of a single-center, blinded, controlled study investigating the effect of the CytoSorb device during CPB. A total of 18 patients undergoing elective CPB surgery with (n = 9) and without (n = 9) HA device were included in the study. MV phenotyping and counting was conducted via flow cytometry and procoagulatory potential was measured by tissue factor-dependent MV assays.

Results

Both study groups exhibited comparable counts and post-operative kinetics in MV subsets. Tissue factor-dependent procoagulatory potential was not detectable in plasma at any timepoint. Post-operative course and laboratory parameters showed no correlation with MV counts in patients undergoing CPB surgery.

Conclusion

Additional artificial surfaces to the CPB-circuit introduced by the use of the HA device showed no effect on circulating MV count and function in these patients. Larger studies are needed to assess and clarify the effect of HA on circulating vesicle counts and function.

Trial registration ClinicalTrials.Gov Identifier: NCT01879176; registration date: June 17, 2013; https://clinicaltrials.gov/ct2/show/NCT01879176

Experience with hemoadsorption (CytoSorb®) in the management of septic shock patients

BACKGROUND

Cytokines and inflammatory mediators are the hallmarks of sepsis. Extracorporeal cytokine hemoadsorption devices are the newer clinical support system to overcome the cytokine storm during sepsis.

AIM

To retrospectively evaluate the clinical outcomes of patients admitted in intensive care unit with septic shock with different etiologies.

METHODS

The laboratory parameters including biomarkers such as procalcitonin, serum lactate and C-reactive protein; and the hemodynamic parameters; mean arterial pressure, vasopressor doses, sepsis scores, cytokine levels and other vital parameters were evaluated. We evaluated these outcomes among survivors and non-survivors.

RESULTS

Of 100 patients evaluated, 40 patients survived. Post treatment, the vasopressors dosage remarkably decreased though it was not statistically different; 34.15% (P = 0.0816) for epinephrine, 20.5 % for norepinephrine (P = 0.3099) and 51% (P = 0.0678) for vasopressin. In the survivor group, a remarkable reduction of biomarkers levels; procalcitonin (65%, P = 0.5859), C-reactive protein (27%, P = 0.659), serum lactate (27%, P = 0.0159) and bilirubin (43.11%; P = 0.0565) were observed from baseline after CytoSorb^® therapy. A significant reduction in inflammatory markers; interleukin 6 and interleukin 10; (87% and 92%, P < 0.0001) and in tumour necrosis factor (24%, P = 0.0003) was also seen. Overall, 28 (28%) patients who were given CytoSorb^® therapy less than 48 h after onset of septic shock survived and the maximum duration of stay for 70% of these patients in intensive care unit was less than 15 d.

CONCLUSION

CytoSorb^® is a safe and well tolerated rescue therapy option in patients with septic shock. However, early (preferably within < 48 h after onset of septic shock) initiation could result in better clinical outcomes. Further randomized trials are needed to define the potential benefits of this new treatment modality.

Hemoadsorption treatment with CytoSorb® in patients with extracorporeal life support therapy: A case series

INTRODUCTION

Extracorporeal life support is an increasingly used technique for respiratory and cardiocirculatory support. Besides primary organ dysfunction, an excessive systemic hyperinflammatory response can be the underlying cause for acute organ failure necessitating extracorporeal life support therapy, or it may be associated with the extracorporeal life support itself. Controlling this overwhelming inflammatory response using CytoSorb^® hemoadsorption has been shown to be associated with improved hemodynamics and restored metabolic balance resulting in preserved organ functions.

METHODS

In this retrospective case series, we describe 23 patients undergoing extracorporeal life support therapy and CytoSorb hemoadsorption. Cytokine levels were monitored, hemodynamic and metabolic variables were recorded, and outcome measures such as duration of organ support, intensive care unit mortality, and hospital mortality were noted.

RESULTS

CytoSorb treatment was associated with a trend toward a reduction in plasma cytokine levels (first treatment median interleukin-6 pre 595 vs post 350 pg/mL (n.s.); second treatment median interleukin-6 317 vs 108 pg/mL, p < 0.05), a reduced vasoplegic response resulting in a reduction in vasopressor requirements (first treatment median norepinephrine pre 0.15 vs post 0.02 µg/kg/min (n.s.); second treatment median norepinephrine 0.1 vs 0.02 µg/kg/min, p < 0.05) as well as rebalancing of deranged metabolic parameters (first treatment median lactate pre-treatment 6 vs post-treatment median lactate 2 mmol/L, p < 0.05). The hemoperfusion treatment was well tolerated and safe, without the occurrence of any CytoSorb device-related adverse events.

CONCLUSION

Hemoadsorption may offer a potentially promising therapeutic option for critically ill patients undergoing extracorporeal life support therapy, with cytokine reduction and a consecutively mitigated inflammatory response, decreased vasoplegia, and improved organ function as seen in our patients.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

Plasma Levels of Myocardial MicroRNA-133a Increase by Intraoperative Cytokine Hemoadsorption in the Complex Cardiovascular Operation

Background

Complex cardiovascular procedures may initiate a systemic inflammatory response syndrome (SIRS) with a massive cytokine release, which is involved in postoperative myocardial injury. Intraoperative cytokine hemoadsorption (HA) mitigates the inflammatory response. Micro ribonucleic acids (miRNAs) are emerging as a marker of myocardial injury.

Methods

This study evaluated if intraoperative cytokine reduction by HA modulates SIRS and affects myocardial injury as measured by miRNA-126, 223 and miRNA-1, 133a, respectively. Twenty-eight patients were assigned into HA (n = 15) and control (C) (n = 13) groups. HA was performed by integrating CytoSorb™ into the extracorporeal circuit.

Results

MiRNA-133a plasma levels were increased postoperatively in both groups but were much higher in the HA group than in the C group at 3 h (P = 0.037) and 18 h (P = 0.017) after reperfusion. MiRNA-1 and miRNA-223 plasma levels were significantly increased postoperatively, but did not differ between groups. The vascular miRNA-126 was not affected.

Conclusion

Intraoperative cytokine HA in cardiovascular operations increased the plasma levels of miRNA-133a, suggesting higher myocardial injury.

Rationale of Hemoadsorption during Extracorporeal Membrane Oxygenation Support

Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support are increasingly used for treating various forms of shock, lung failure, protected interventions and life support including resuscitation. Most patients on ECMO are affected by a systemic inflammatory response caused by the underlying disease as well as the ECMO support itself, which contributes to vasoplegia, multi-organ failure, deterioration and death. Unfortunately, effective strategies for control of inflammation and related organ failure and shock on ECMO are lacking. Recently, a new polystyrene-based device for hemoadsorption, which aims to reduce excessive levels of inflammatory molecules such as interleukins, cytokines as well as damage- and pathogen-associated molecular patterns, has become available. Here we summarize the rationale, available data and technical aspects of polystyrene-based hemoadsorption during ECMO support, and give recommendations based on existing experience.

Affinity binding of aptamers to agarose with DNA tetrahedron for removal of hepatitis B virus surface antigen

DNA nanostructures are effective intermediates for immobilizing biomolecules because of their high level of controllability, the flexibility to create desired nanostructures through precision "bottom-up" assembly and the convenience to building fine nanostructures. The purpose of this study was to demonstrate the potential use of aptamers bound to agarose through a DNA tetrahedral structure to make a novel type of immunosorbent for the removal of hepatitis B virus surface antigens. Our results show that the proposed immunosorbent exhibits favorable biocompatibility and specificity. Electrophoresis and confocal microscopy were used to confirm the formation of immunosorbents. The ARCHITECT HBsAg assay was performed to quantitatively measure hepatitis B surface antigen. The cytotoxic potential of the immunosorbent was determined by an in vitro viability assay using V79 lung fibroblasts, demonstrating that the immunosorbents are noncytotoxic. The high adsorption capacity of the novel DNA nanostructure-based adsorbents towards hepatitis B surface antigen indicated the potential application of these materials for the treatment of Hepatitis B infection.

Extracorporeal cytokine adsorption in septic shock: A proof of concept randomized, controlled pilot study

BACKGROUND

The aim of this proof of concept, prospective, randomized pilot trial was to investigate the effects of extracorporeal cytokine removal (CytoSorb®) applied as a standalone treatment in patients with septic shock.

METHODS

20 patients with early (<24 h) onset of septic shock of medical origin, on mechanical ventilation, norepinephrine>10 μg/min, procalcitonin (PCT) > 3 ng/mL without the need for renal replacement therapy were randomized into CytoSorb (n = 10) and Control groups (n = 10). CytoSorb therapy lasted for 24 h. Clinical and laboratory data were recorded at baseline (T₀), T₁₂, T₂₄, and T₄₈ hours.

RESULTS

Overall SOFA scores did not differ between the groups. In the CytoSorb-group norepinephrine requirements and PCT concentration decreased significantly (norepinephrine: CytoSorb: T₀ = 0.54[IQR:0.20-1.22], T₄₈ = 0.16[IQR:0.07-0.48], p = .016; Controls: T₀ = 0.43[IQR:0.19-0.64], T₄₈ = 0.25[IQR:0.08-0.65] μg/kg/min; PCT: CytoSorb: T₀ median = 20.6[IQR: 6.5-144.5], T₄₈ = 5.6[1.9-54.4], p = .004; Control: T₀ = 13.2[7.6-47.8], T₄₈ = 9.2[3.8-44.2]ng/mL). Big-endothelin-1 concentrations were also significantly lower in the CytoSorb group (CytoSorb: T₀ = 1.3 ± 0.6, *T₂₄ = 1.0 ± 0.4, T₄₈ = 1.4 ± 0.8, *p = .003; Control: T₀ = 1.1 ± 0.7, T₂₄ = 1.1 ± 0.6, T₄₈ = 1.2 ± 0.6 pmol/L, p = .115). There were no CytoSorb therapy-related adverse events.

CONCLUSIONS

This is the first trial to investigate the effects of early extracorporeal cytokine adsorption treatment in septic shock applied without renal replacement therapy. It was found to be safe with significant effects on norepinephrine requirements, PCT and Big-endothelin-1 concentrations compared to controls.

TRIAL REGISTRATION

The study has been registered on ClinicalTrials.gov, under the registration number of NCT02288975, registered 13 November 2014.

Blood Purification With CytoSorb in Critically Ill Patients: Single-Center Preliminary Experience

The CytoSorb adsorber, a blood purification therapy, is able to remove molecules in the 5-60 kDa range which comprises the majority of inflammatory mediators and some endogenous molecules. We aimed to evaluate CytoSorb therapy on clinical outcomes in critically ill patients. A retrospective case series study, from February 2016 to May 2017, was performed in 40 patients with multiple organ failure who received CytoSorb treatment. There were 28 patients with cardiogenic shock, 2 with septic shock, 9 with acute respiratory distress syndrome, and 1 with liver failure. Nineteen patients (47%) underwent extracorporeal membrane oxygenation, 11 (27%) had an intra-aortic balloon pump, 9 (22%) were implanted with Impella, 6 (15%) had a ventricular assist device, and 18 (45%) were treated with continuous veno-venous hemofiltration. After CytoSorb treatment, total bilirubin decreased from 11.6 ± 9.2 to 6.8 ± 5.1 mg/dL (P = 0.005), lactate from 12.1 ± 8.7 to 2.9 ± 2.5 mmol/L (P < 0.001), CPK from 2416 (670-8615) to 281 (44-2769) U/L (P < 0.001) and LDH from 1230 (860-3157) to 787 (536-1148) U/L (P < 0.001). The vasoactive-inotropic score after 48 h of treatment was reduced to 10 points, P = 0.009. Thirty-day mortality was 55% and ICU mortality was 52.5% at expected ICU mortality of 80%. Our study shows that CytoSorb^TM treatment is effective in reducing bilirubin, lactate, CPK and LDH, in critically ill patients mainly due to cardiogenic shock. There is a need for randomized controlled trials to conclude on the potential benefits blood purification with CytoSorb in critically ill patients.

Extracorporeal membrane oxygenation and cytokine adsorption

Extracorporeal membrane oxygenation (ECMO) is an increasingly used technology for mechanical support of respiratory and cardio-circulatory failure. Excessive systemic inflammatory response is observed during sepsis and after cardiopulmonary bypass (CPB) with similar clinical features. The overwhelming inflammatory response is characterized by highly elevated pro- and anti-inflammatory cytokine levels. The excessive cytokine release during the overwhelming inflammatory response may result in multiple organ damage and failure. During ECMO therapy activation of complement and contact systems occur which may be followed by cytokine release. Controlling excessively increased cytokines may be considered as a valuable treatment option. Hemoadsorption therapy may be used to decrease cytokine levels in case of excessive inflammatory response and due to its unspecific adsorptive characteristics also substances like myoglobin, free hemoglobin or bilirubin. Controlling pro-inflammatory response with hemoadsorption may have positive impact on the endothelial glycocalix and also may be advantageous for maintenance of the vascular barrier function which plays a pivotal role in the development of tissue edema and oxygen mismatch. Hemoadsorption therapy seems to offer a promising new option for the treatment of patients with overwhelming inflammatory response leading to faster hemodynamic and metabolic stabilization finally resulting in preserved organ functions.