Cytokine Hemoadsorption As Rescue Therapy for Critically Ill Patients with SARS-CoV-2 Pneumonia with Severe Respiratory Failure and Hypercytokinemia

Abstract Background : A dysregulated inflammatory response, known as “cytokine storm”, plays an important role in the pathophysiology of coronavirus 2019 disease (COVID-19). There is a subgroup of patients who develop a hyperinflammatory response with severe respiratory failure and organ dysfunction with high mortality. Identifying these patients is outstanding as they could benefit from specific therapies, such as cytokine removal by hemoadsorption. Methods : Single-center, observational and prospective study of critically ill patients with SARS-CoV-2 pneumonia, severe acute respiratory failure and hypercytokinemia. All patients received cytokine hemoadsorption using Cytosorb ® (Cytosorbents Europe, Berlin, Germany). The indication for treatment was acute respiratory failure, inadequate prone response, and hypercytokinemia. Results : A total of 343 patients were admitted to the ICU due to SARS-Cov-2 infection between March 3, 2020, to June 22, 2020. Of these, six patients [5 (83.3%) men; mean age 57 (10.5) years; SOFA 5 (1.4); mean Acute Physiology And Chronic Health Evaluation (APACHE) II score 19.5 (6)] underwent hemoadsorption with Cytosorb ® . All patients fulfilled the Berlin criteria for severe acute respiratory distress syndrome (ARDS), underwent prone positioning, and were on mechanical ventilation for 15.2 (7.2) days. One session of 16 (9.0) hours duration was performed. IL-6 levels were significantly reduced [(pre- hemoadsorption levels 17.367 (4.539– 22.532) pg/ml; post-hemoadsorption levels 2.403 (917 – 3.724) pg/ml, p = 0.043], and improvements in oxygenation were observed [pre-hemoadsorption PaO 2 /FiO 2 ratio was 103 (18.4), post- hemoadsorption PaO2/FiO2 ratio was 222 (20.9), p = 0.029]. We documented the clinical improvement and rapid reversal of organ dysfunction [pre-hemoadsorption Sequential Organ Failure Assessment (SOFA) score 9 (4.7); post- hemoadsorption SOFA score 7.7 (5.4), p = 0.046]. Inflammatory markers (C-reactive protein, D-dimer, and ferritin) also improved significantly. Mean ICU stay was 17.2 (8.0) days. ICU and in-hospital mortality was 33.7%. Conclusions : In our cohort, patients with SARS-CoV-2 pneumonia and severe acute respiratory failure and hypercytokinemia who received cytokine hemoadsorption, an important reduction in IL-6 levels and improvements in oxygenation and SOFA score were observed.