Abstract
Introduction: Uncontrolled systemic inflammation may occur in severe coronavirus disease 19 (COVID-19). We have previously shown that endotoxemia, presumably from the gut, may complicate COVID-19. However, the role of endotoxin adsorbent (EA) therapy to mitigate organ dysfunction in COVID-19 has not been explored. Methods: We conducted a retrospective observational study in COVID-19 patients who received EA therapy at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between March 13 and April 17, 2020. Relevant clinical and laboratory data were collected by inpatient chart review. Results: Among 147 hospitalized COVID-19 patients, 6 patients received EA therapy. All of the 6 patients had severe COVID-19 infection with acute respiratory distress syndrome (ARDS). Among these, 5 of them were mechanically ventilated and 4 had complications of secondary bacterial infection. The endotoxin activity assay (EAA) results of pre-EA therapy ranged from 0.47 to 2.79. The choices of EA therapy were at the discretion of attending physicians. One patient was treated with oXiris® along with continuous renal replacement therapy, and the others received polymyxin B hemoperfusion sessions. All patients have survived and were finally free from the mechanical ventilation as well as had improvement in PaO2/FiO2 ratio and decreased EAA level after EA therapy. Conclusions: We demonstrated the clinical improvement of severe COVID-19 patients with elevated EAA level upon receiving EA therapy. However, the benefit of EA therapy in COVID-19 ARDS is still unclear and needs to be elucidated with randomized controlled study.
References
1.
Huang
C
, Wang
Y
, Li
X
, Ren
L
, Zhao
J
, Hu
Y
, Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China
. Lancet
. 2020
;395
(10223
):497
–506
.2.
Arunachalam
PS
, Wimmers
F
, Mok
CKP
, Perera
R
, Scott
M
, Hagan
T
, Systems biological assessment of immunity to mild versus severe COVID-19 infection in humans
. Science
. 2020 Sep 4
;369
(6503
):1210
–20
.3.
Beigel
JH
, Tomashek
KM
, Dodd
LE
, Mehta
AK
, Zingman
BS
, Kalil
AC
, Remdesivir for the treatment of Covid-19: preliminary report
. N Engl J Med
. 2020 Sep 3
;383
(10
):994
.4.
Shanmugaraj
B
, Siriwattananon
K
, Wangkanont
K
, Phoolcharoen
W
. Perspectives on monoclonal antibody therapy as potential therapeutic intervention for coronavirus disease-19 (COVID-19)
. Asian Pac J Allergy Immunol
. 2020
;38
(1
):10
–8
. .5.
Guan
WJ
, Ni
ZY
, Hu
Y
, Liang
WH
, Ou
CQ
, He
JX
, Clinical characteristics of coronavirus disease 2019 in China
. N Engl J Med
. 2020 Feb 28
. Epub ahead of print.6.
Zhou
F
, Yu
T
, Du
R
, Fan
G
, Liu
Y
, Liu
Z
, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study
. Lancet
. 2020
;395
(10229
):1054
–62
.7.
Opal
SM
. The host response to endotoxin, antilipopolysaccharide strategies, and the management of severe sepsis
. Int J Med Microbiol
. 2007
;297
(5
):365
–77
. .8.
Munford
RS
. Sensing gram-negative bacterial lipopolysaccharides: a human disease determinant?
Infect Immun
. 2008
;76
(2
):454
–65
. .9.
Danner
RL
, Elin
RJ
, Hosseini
JM
, Wesley
RA
, Reilly
JM
, Parillo
JE
. Endotoxemia in human septic shock
. Chest
. 1991
;99
(1
):169
–75
. .10.
Kudo
K
, Binh
NG
, Manabe
T
, Co
DX
, Tuan
ND
, Izumi
S
, Clinical preparedness for severe pneumonia with highly pathogenic avian influenza A (H5N1): experiences with cases in Vietnam
. Respir Investig
. 2012
;50
(4
):140
–50
. .11.
Yokoyama
T
, Tateishi
K
, Tsushima
K
, Agatsuma
T
, Yamamoto
H
, Koizumi
T
, A case of severe ARDS caused by novel swine-origin influenza (A/H1N1pdm) virus: a successful treatment with direct hemoperfusion with polymyxin B-immobilized fiber
. J Clin Apher
. 2010
;25
(6
):350
–3
. .12.
Binh
NG
, Manabe
T
, Co
DX
, Tuan
ND
, Thach
PT
, Kudo
K
. Polymyxin-B-immobilized-fiber column hemoperfusion with oseltamivir treatment for ARDS due to influenza H1N1/09
. Respirol Case Rep
. 2015
;3
(2
):57
–60
. .13.
Takeda
S
, Munakata
R
, Abe
S
, Mii
S
, Suzuki
M
, Kashiwada
T
, Hypercytokinemia with 2009 pandemic H1N1 (pH1N1) influenza successfully treated with polymyxin B-immobilized fiber column hemoperfusion
. Intensive Care Med
. 2010
;36
(5
):906
–7
. .14.
The ARDS Definition Task Force
. Acute respiratory distress syndrome: the Berlin definition
. JAMA
. 2012
;307
(23
):2526
–33
.15.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
. KDIGO clinical practice guideline for acute kidney injury
. Kidney Int
. 2012
;2
:1
–138
.16.
WHO
. COVID-19: WHO Thailand Situation Reports
. World Health Organization
; 2020
. Available from: https://www.who.int/thailand/emergencies/novel-coronavirus-2019/situation-reports.17.
Romaschin
AD
, Harris
DM
, Ribeiro
MB
, Paice
J
, Foster
DM
, Walker
PM
, A rapid assay of endotoxin in whole blood using autologous neutrophil dependent chemiluminescence
. J Immunol Methods
. 1998
;212
(2
):169
–85
. .18.
Marshall
JC
, Foster
D
, Vincent
JL
, Cook
DJ
, Cohen
J
, Dellinger
RP
, Diagnostic and prognostic implications of endotoxemia in critical illness: results of the MEDIC study
. J Infect Dis
. 2004
;190
(3
):527
–34
. .19.
Koch
RM
, Diavatopoulos
DA
, Ferwerda
G
, Pickkers
P
, de Jonge
MI
, Kox
M
. The endotoxin-induced pulmonary inflammatory response is enhanced during the acute phase of influenza infection
. Intensive Care Med Exp
. 2018
;6
(1
):15
. .20.
Lin
E
, Lowry
SF
. The human response to endotoxin
. Sepsis
. 1998
(2
):255
–62
. .21.
Wong
CK
, Lam
CW
, Wu
AK
, Ip
WK
, Lee
NL
, Chan
IH
, Plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome
. Clin Exp Immunol
. 2004
;136
(1
):95
–103
. .22.
Mahallawi
WH
, Khabour
OF
, Zhang
Q
, Makhdoum
HM
, Suliman
BA
. MERS-CoV infection in humans is associated with a pro-inflammatory Th1 and Th17 cytokine profile
. Cytokine
. 2018
;104
:8
–13
. .23.
Morens
DM
, Taubenberger
JK
, Fauci
AS
. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness
. J Infect Dis
. 2008
;198
(7
):962
–70
. .24.
Morris
DE
, Cleary
DW
, Clarke
SC
. Secondary bacterial infections associated with influenza pandemics
. Front Microbiol
. 2017
;8
:1041
. .25.
Brundage
JF
. Interactions between influenza and bacterial respiratory pathogens: implications for pandemic preparedness
. Lancet Infect Dis
. 2006
;6
(5
):303
–12
. .26.
Chien
YW
, Klugman
KP
, Morens
DM
. Bacterial pathogens and death during the 1918 influenza pandemic
. N Engl J Med
. 2009
;361
(26
):2582
–3
. .27.
Cilloniz
C
, Ewig
S
, Menendez
R
, Ferrer
M
, Polverino
E
, Reyes
S
, Bacterial co-infection with H1N1 infection in patients admitted with community acquired pneumonia
. J Infect
. 2012
;65
(3
):223
–30
.28.
Jain
S
, Kamimoto
L
, Bramley
AM
, Schmitz
AM
, Benoit
SR
, Louie
J
, Hospitalized patients with 2009 H1N1 influenza in the United States, April–June 2009
. N Engl J Med
. 2009
;361
(20
):1935
–44
. .29.
Yaguchi
A
, Yuzawa
J
, Klein
DJ
, Takeda
M
, Harada
T
. Combining intermediate levels of the Endotoxin Activity Assay (EAA) with other biomarkers in the assessment of patients with sepsis: results of an observational study
. Crit Care
. 2012
;16
(3
):R88
. .30.
Sirivongrangson
P
, Kulvichit
W
, Payungporn
S
, Pisitkun
T
, Chindamporn
A
, Peerapornratana
S
, Endotoxemia and circulating bacteriome in severe COVID-19 patients
. Intensive Care Med Exp
. 2020
;8
(1
):72
. .31.
Tsushima
K
, Kubo
K
, Koizumi
T
, Yamamoto
H
, Fujimoto
K
, Hora
K
, Direct hemoperfusion using a polymyxin B immobilized column improves acute respiratory distress syndrome
. J Clin Apher
. 2002
;17
(2
):97
–102
. .32.
Nakamura
T
, Kawagoe
Y
, Matsuda
T
, Shoji
H
, Ueda
Y
, Tamura
N
, Effect of polymyxin B-immobilized fiber on blood metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 levels in acute respiratory distress syndrome patients
. Blood Purif
. 2004
;22
(3
):256
–60
. .33.
Tsushima
K
, Kubo
K
, Yoshikawa
S
, Koizumi
T
, Yasuo
M
, Furuya
S
, Effects of PMX-DHP treatment for patients with directly induced acute respiratory distress syndrome
. Ther Apher Dial
. 2007
;11
(2
):138
–45
. .34.
Nakano
M
, Yoshida
S
, Nakayama
T
, Ogushi
F
, Hanibuchi
M
, Nishioka
Y
. [A Case of Acute Respiratory Distress Syndrome (ARDS) accompanied with influenza (H1N1) 2009 successfully treated with polymyxin B-immobilized fiber column-direct hemoperfusion (PMX-DHP)]
. Kansenshogaku Zasshi
. 2015
;89
(3
):416
–21
. .35.
Yatera
K
, Yamasaki
K
, Kawanami
T
, Tokuyama
S
, Ogoshi
T
, Kouzaki
M
, A case of successful treatment with polymyxin B-immobilized fiber column direct hemoperfusion in acute respiratory distress syndrome after influenza A infection
. Intern Med
. 2011
;50
(6
):601
–5
. .36.
List of medical devices for expanded use in relation to the COVID-19 pandemic: Government of Canada
. Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/announcements/interim-order-importation-sale-medical-devices-covid-19/list-expanded-use.html.37.
Ronco
C
, Reis
T
, De Rosa
S
. Coronavirus epidemic and extracorporeal therapies in intensive care: si vis pacem para bellum
. Blood Purif
. 2020
;49
(3
):225
–8
.38.
Srisawat
N
, Tungsanga
S
, Lumlertgul
N
, Komaenthammasophon
C
, Peerapornratana
S
, Thamrongsat
N
, The effect of polymyxin B hemoperfusion on modulation of human leukocyte antigen DR in severe sepsis patients
. Crit Care
. 2018
;22
(1
):279
. .39.
De Rosa
S
, Cutuli
SL
, Ferrer
R
, Antonelli
M
, Ronco
C
, Group
CEC
. Polymyxin B hemoperfusion in COVID-19 patients with endotoxic shock: case series from EUPHAS II registry
. Artif Organs
. 2020
. Epub ahead of print.40.
Malard
B
, Lambert
C
, Kellum
JA
. In vitro comparison of the adsorption of inflammatory mediators by blood purification devices
. Intensive Care Med Exp
. 2018
;6
(1
):12
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