ABSTRACT
Background: A baseline hyperinflammatory state afflict COVID-19 positive patients (pts). AKI as a final common pathway of systemic inflammation and increased immunologic response leading to uncontrolled circulating levels of pro-inflammatory mediators and direct cytokine-induced organ damage. HemoDialysis expanded (HDx) represents an innovative strategy to remove uremic toxins up to 50 Kda, thanks to the medium cut-off membrane (MCO) and internal convection. Transcription of proinflammatory cytokines in peripheral leukocytes is markedly reduced and removal of soluble mediators of inflammation is enhanced by HDx. In vitro studies confirm that HDx limit neutrophil activation by decrease of ROS, TNF-alpha and IL6 and increase of apoptosis. Aim of this study is to evaluate the response to treatment with HDx and HF-HD in AKI due to COVID-19 disease. Methods: Six pts were enrolled in a retrospective observational study: 3 pts were treated with HF-HD (FX80-Fresenius) and 3 with HDx (Theranova 400-Baxter) during COVID-19 infection. 2 pts treated with HDx and 1 with HF-HD showed hemodynamic instability and need for vasopressors. They were daily assessed using the following: urea, creatinine, C-reactive protein (CRP), procalcitonin (PCT), D-Dimer and Albumin. The values have been reported as mean±SD. Results: HDx (Qb=218±48 ml/m) discovered in every patient a significant reduction for CRP (-59.7% average) and PCT (-11,2% average), whereas HF-HD (Qb=205±27 ml/m) showed an opposite trend (+69,1% and +39,1% average). Moreover HDx induce a greater reduction of D-Dimer (51.4% vs 19.8% average), Urea and serum Creatinine in comparison to HF-HD (average), (Tab.1) and better hemodynamic stability (Pam 75 vs 67 mm/Hg). Conclusions: HDx effectively impact on inflammation and renal markers, compared to HF-HD, in COVID-19 positive. HDx, due to the increased clearance of cytokines, has recently been confirmed as a support for COVID-19 positive treatment in some Italian dialysis centers. Our preliminary results has to be confirmed by enlarged studies but in the meantime could help to build a new scientific evidence.
ABSTRACT
Introduction: HemoDialysis eXpanded (HDx) represents an innovative strategy to remove uremic toxins of Large-Medium Molecular weight (LMMs, up to 45 Kda) thanks to the medium cutoff membranes (MCO) and internal convection. Transcription of pro-inflammatory cytokines in peripheral leukocytes is markedly reduced and removal of soluble mediators of inflammation is enhanced after HDx. Also in vitro studies confirmed that HDx is associated with a limitation of neutrophil activation: decrease of ROS, TNF-alpha and IL6 production, and increase of apoptosis. The aim of this study is to evaluate the clinical response to treatment with HDx during AKI related to sepsis. Methods: An 88 year old woman with a history of ischemic heart disease,heart failure and chronic kidney disease stage III-B KDOQI (eGFR 31 ml/m') had been in his usual state of health until 10 days before admission, when fever developed associated with diarrhea and urinary tract infection (UTI). Treated at home with Ceftriaxone 1 g/day without improvement, for the onset of oligoanuria and the detection of sepsis associated with bronchopneumonia and AKI, she was hospitalized. Microangiopathic hemolitic anemia (MAHA) is excluded. He then comes to daily renal replacement theraphy (RRT) through sustained low efficiency dialysis (SLED) and start antibiotic therapy with Imipenem and Teicoplanina. After 72 hours, for the worsening of leukocytosis, the persistence of high values of inflammation indexes and anuria the patient was undergo to daily HDx using Theranova® 400 (1.7m2, Baxter). Antibiotic therapy was still unchanged. After 9 days of this treatment there was a normalization of the inflammation indexes, diuresis recovery and HDx stop. At T0-T3-T12 were evaluated: complete blood count, Procalcitonin (PCT), C-Reactive Protein (CRP) and albumin. Serum creatinine, urea and the daily urine output have been monitored to follow progression of renal dysfunction. Results: HDx (Qb = 255 ± 45ml/min, TT 235 ± 27 m) shows a significant reduction at 12 days for Leukocyte (WBC), Nutrophils, Lymphocytes, Platelets (PLT), PCT and CRP, whereas the albumin is unchanged (Tab.1). HDx also induces relevant RR of Urea (73.5%) and serum creatinine (75.2%). Conclusions: HDx theraphy, through the use of a MCO membrane, effectively is involved on resolution of sepsis and AKI of our patient compared to SLED, despite unchanged antibiotic therapy. Probably this is due to interesting results of HDx on inflammation and increased clearance of cytokines. His possible support in the treatment of positive COVID-19, in fact, has recently been postulated in some Italian dialysis centers, even in the absence of trials to confirm these evidences. [Formula presented] No conflict of interest