key: cord-0846318-izq70z47
authors: Al-Qudsi, Omar; Whitson, Bryan; Bhatt, Amar; Chucta, Sheila; Tripathi, Ravi
title: A Case of Cytokine Hemofiltration and ECLS as Treatment of COVID-19 Respiratory Failure
date: 2020-06-09
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.05.082
sha: e80dae45a7a31da77b8e1ec80f194fb61eb59bb2
doc_id: 846318
cord_uid: izq70z47

Abstract Background Discovery of the novel severe acute respiratory syndrome coronavirus 2 (n-SARS-CoV-2) in late 2019 has brought with it a renewed interest in methods of inflammatory mitigation, particularly due to reports of a cytokine release syndrome playing a pathogenic role [1]. One method of decreasing inflammation is through hemofiltration in combination with a dialysis membrane that has a large cutoff for protein permeability (high-cutoff/HCO), thereby capturing inflammatory cytokines and attenuating their harmful side effects. The authors report a patient with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 infection, requiring Veno-Venous Extracorporeal Life Support (VV-ECLS) who was treated with cytokine hemofiltration and showed clinical improvement. Case Summary Our patient is a 53 year-old female who presented with coronavirus infection and respiratory failure culminating in hypoxemia refractory to conventional mechanical ventilation. She was cannulated onto veno-venous extra-corporeal life support and treated with cytokine hemofiltration using a high-cutoff filter. Following treatment, inflammatory markers improved along with compliance and oxygenation. She was decannulated from ECLS shortly thereafter. IRB approval was waived due to the single case report nature. Consent was obtained for use of images and case data. Discussion Inflammatory modulation has been theorized to be beneficial in the management of organ failure secondary to coronavirus infection. A cytokine release syndrome (CRS) has been implicated in this disease’s pathogenesis. Cytokine hemofiltration is one modality to mitigate harmful inflammation. Our patient demonstrated remarkable improvement with treatment and to our knowledge represents the first report of cytokine hemofiltration as management of COVID-19 respiratory failure in conjunction with VV-ECLS. This therapy warrants further evaluation as a treatment option.

A hyperactive immune response has been implicated in COVID-19 respiratory failure. 24

Hemofiltration with a dialysis membrane designed to remove cytokines offers a potential 25 avenue for treatment. Discovery of the novel severe acute respiratory syndrome coronavirus 2 (n-SARS-CoV-2) in late 74 2019 has brought with it a renewed interest in methods of inflammatory mitigation, particularly 75 due to reports of a cytokine release syndrome playing a pathogenic role [1] . One method of 76 decreasing inflammation is through hemofiltration in combination with a dialysis membrane 77 that has a large cutoff for protein permeability (high-cutoff/HCO), thereby capturing 78 inflammatory cytokines and attenuating their harmful side effects. The authors report a patient 79 with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 infection, 80

requiring Veno-Venous Extracorporeal Life Support (VV-ECLS) who was treated with cytokine 81 hemofiltration and showed clinical improvement. 82

Our patient is a 53 year-old female who presented with coronavirus infection and respiratory 84 failure culminating in hypoxemia refractory to conventional mechanical ventilation. She was 85 cannulated onto veno-venous extra-corporeal life support and treated with cytokine 86 hemofiltration using a high-cutoff filter. Following treatment, inflammatory markers improved 87 along with compliance and oxygenation. She was decannulated from ECLS shortly thereafter. 88 IRB approval was waived due to the single case report nature. Consent was obtained for use of 89 images and case data. In the 36 hours following cytokine filtration, compliance was noted to increase three-fold 155 (10.4cm/mlH2O) and her P:F ratio rose to 240 (table 1) . Her CXR also demonstrated a 156 remarkable progression, with near-complete resolution of her bilateral opacities and air 157 bronchograms (figure 1). She was subsequently weaned and decannulated from VV-ECLS over 158 the next four days and tracheostomy was performed to assist with liberation from mechanical 159 ventilation. Her tracheostomy has since been reversed and she has been discharged to rehab. 

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Can we use interleukin-6 (IL-6) blockade for coronavirus disease 2019 228 (COVID-19)-induced cytokine release syndrome (CRS)?

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Extracorporeal membrane oxygenation and cytokine adsorption

Changes in parameters of oxygenation that correspond to treatment with a cytokine hemofilter while on VV-ECLS.