Plasma markers of Covid-19 severity: A pilot study

SARS-CoV-2 infected patients show heterogeneous clinical presentations ranging from mild symptoms to severe respiratory failure and death. Consequently, various markers reflect certain disease presentations. Our cohort included moderate (n = 10) and severe (n = 10) COVID-19 patients, and 10 healthy controls. We determined plasma levels of nine acute phase proteins by nephelometry, full-length (M65), caspase-cleaved (M30) cytokeratin 18, and ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type-1 motif 13) by ELISA. In addition, we examined whole plasma N-glycosylation by capillary gel electrophoresis coupled to laser-induced fluorescence detection. When compared to healthy controls, COVID-19 patients had significantly lower concentrations of ADAMTS13 and albumin (ALB) but higher M30, M65, alpha-1-acid glycoprotein, alpha1-antitrypsin (AAT), ceruloplasmin, haptoglobin, and highsensitivity C-reactive protein. The concentrations of alpha1-antichymotrypsin, alpha2-macroglobulin and serum amyloid A proteins did not differ. We found significantly higher levels of AAT and M65 but lower ALB in severe compared to moderate COVID-19 patients. N-glycan analysis of the serum proteome revealed increased levels of oligomannose and sialylated di-antennary glycans, while the non-sialylated di-antennary glycan A2G2 significantly decreased in COVID-19 patients compared to controls. COVID-19-associated changes in levels and N-glycosylation of specific plasma proteins highlight involvement of different pathophysiological mechanisms and grant further investigations.

Efficacy and safety of garadacimab in patients with severe COVID-19

Introduction: Garadacimab (GAR;CSL312), a fully human IgG4 monoclonal antibody, inhibits the kallikrein-kinin pathway at a key initiator, FXIIa, and may play a protective role in the progression of COVID-19 related respiratory disease. Aims and objectives: This placebo (PL)-controlled study evaluated efficacy and safety of GAR plus standard of care (SOC) vs PL plus SOC in patients (pts) with severe COVID-19. Method(s): Pts were randomised (1:1) to GAR (700 mg IV) or PL plus SOC. Primary endpoint was incidence of endotracheal intubation (TI) or death up to Day 28. Key secondary endpoints included all-cause mortality and safety (reporting of AEs). aPTT, FXII levels and FXIIa-mediated kallikrein activity (FXIIa-mKA) were measured to indicate target activation. Result(s): In the ITT analysis set (N=124), baseline demographics were balanced between study groups (GAR, n=63;PL, n=61). Incidence of TI or death was 22% for GAR vs 26% (P=0.274) for PL. No difference in all-cause mortality was observed (crude rate: GAR 17.5% vs PL 18.0%). GAR was associated with fewer TEAEs (60.3% vs 67.8%) and SAEs (34 vs 45 events) vs PL. No GAR-related deaths or bleeding were reported, despite permitted heparin coadministration. aPTT prolongation and increased FXII levels were observed with GAR vs PL to Day 14, while FXIIa-mKA was suppressed to Day 28. Conclusion(s): In pts with severe COVID-19, GAR did not confer a clinical benefit over PL. Transient aPTT prolongation and suppressed FXIIa-mKA showed target engagement of GAR that was not associated with bleeding even with co-administered heparin. The safety profile of GAR in pts with severe COVID-19 was benign, as reported in pts treated with GAR for hereditary angioedema.

Time-dependent molecular motifs of pulmonary fibrogenesis in COVID-19

Background: In COVID-19 survivors, there is an increased prevalence of pulmonary fibrosis of which the underlying molecular mechanisms are poorly understood. Aims and objectives: In this study, we aimed to gain insights into the evolution of pulmonary fibrogenesis in COVID19. Method(s): In this multicentric study, n=12 patients who succumbed to COVID-19 due to progressive respiratory failure were assigned to an early and late group (death within <=7 and >7 days of hospitalization, respectively) and compared to n=11 healthy controls;mRNA and protein expression were analyzed using a fibrosis-specific panel and immunostaining. Biological pathway analysis was performed using two different gene expression databases. Result(s): Median duration of hospitalization until death was 3 (IQR25-75, 3-3.75) and 14 (12.5-14) days in the early and late group, respectively. Fifty-eight out of 770 analyzed genes showed a significantly altered expression signature in COVID-19 compared to controls in a time-dependent manner. The entire study group showed an increased expression of Bone Marrow Stromal Cell Antigen 2 (BST2) and interleukin-1 receptor 1 (IL1R1), independent of hospitalization time. In the early group, there was increased activity of inflammation-related genes and pathways, while fibrosis-related genes (particularly PDGFRB) and pathways dominated in the late group. Conclusion(s): After the first week of hospitalization, there is a shift from pro-inflammatory to fibrogenic activity in severe COVID-19. IL1R1 and PDGFRB may serve as potential therapeutic targets in future studies.

Lung Transplantation in Patients with Irreversible Lung Injury Due to SARS-CoV-2: A Single-Center Experience

Background: Lung transplantation (LTx) has been demonstrated to be a feasible therapy in patients with irreversible lung injury due to SARS-CoV-2. Aim of this retrospective study was to present our experience with LTx in SARS-CoV-2 patients. Method(s): Records of the 136 patients who underwent LTx between January 2021 and August 2022 at our institution were retrospectively reviewed. LTx was performed in SARS-CoV-2 patients who showed radiological evidence of irreversible lung failure, after failed attempts of weaning off mechanical ventilation (MV) and ECMO;showed single-organ dysfunction;were SARS-CoV-2 negative, preferably <65 years old and awake under MV and ECMO support. Graft survival was compared between COVID-19 LTx patients and contemporary patients transplanted for other indications. Median follow-up amounted to 7.6 (5.2-14.5) months. Result(s): Among the 79 patients with SARS-CoV-2 lung failure referred for LTx, 9 (11%) patients were listed, 8 of them being transplanted between January 2021 and August 2022. One patient died while on the waiting list. All were on MV and ECMO support (awake in 6 cases) for a median ECMO support time of 75 (38.5-152.8) days. Four (50%) patients were male and median age was 52 (37-57) years. All patients underwent bilateral LTx on ECMO support that was weaned off in all patients at the end of Tx. After LTx, 2 (25%) patients showed a primary graft dysfunction (PGD) score grade 3 at 72 hours and required reinstitution of veno-venous (n = 1) and veno-arterial (n = 1) ECMO support that was successfully weaned after 7 and 6 days, respectively. One patient (12.5%) required rethoracotomy for bleeding, and two (25%) patients required new hemodialysis treatment, with recovery of renal function in all patients. Median MV time amounted to 8 days (1-30), median intensive care unit stay to 19 (13-26) days, and median hospital stay to 91 (62-103) days. No patient died in-hospital. At 1-year follow-up, graft survival was 100% in SARS-CoV-2 LTx patients and 95% for patients (n = 128) transplanted for other indications (p = 0.539). Conclusion(s): Lung transplantation in highly selected SARS-CoV-2 patients yielded excellent posttransplant results. Graft survival was comparable between patients transplanted for SARS-COV-2 pneumonia and patients transplanted for other indications. A multidisciplinary approach is of paramount importance to successfully bridge these patients to transplantation and to guarantee a complete patient functional recovery after transplantation.

Phase 3 RCT of C5a-Specific Vilobelimab in Severe COVID-19 Pneumonia

Background: Blocking the C5a-C5aR axis in COVID-19 patients could improve outcomes by limiting myeloid cell infiltration in damaged organs and preventing excessive lung inflammation and endothelialitis. Aims and Objectives: Vilobelimab (VILO), an anti-C5a mAb that preserves the membrane attack complex (MAC), was tested in a Phase III adaptively designed multicenter, double-blind placebo (P)-controlled study for survival in critically ill COVID-19 patients. Method(s): COVID-19 pneumonia patients (N=369;VILO n=178, P n=191) within 48 hrs of intubation were randomly assigned to receive 6, 800 mg infusions of VILO or P on top of standard of care. Primary outcome was 28-day allcause mortality. Result(s): 28-day all-cause mortality was 31.7% VILO vs 41.6% P (Kaplan-Meier estimates;Cox regression site stratified, HR 0.73;95%CI:0.50-1.06;P=0.094) with a 22.7% relative mortality reduction to Day 60. In predefined primary outcome analysis without site stratification, VILO significantly reduced 28-day mortality (HR 0.67;95%CI:0.48-0.96;P=0.027);needed to treat number, 10 to save 1. VILO significantly reduced 28-day mortality in severe patients with baseline WHO ordinal scale score of 7 (n=237, HR 0.62;95%CI:0.40-0.95;P=0.028) or severe ARDS/PaO2/FiO2<=100 mmHg (n=98, HR 0.55;95%CI:0.30-0.98;P=0.044) or eGFR<60 mL/min/1.73m2 (n=108, HR 0.55;95%CI:0.31-0.96;P=0.036). Treatment emergent AEs were 90.9% VILO vs 91.0% P. Infections were comparable;VILO (62.9%), P (59.3%). Serious AEs were 58.9% VILO, 63.5% P. Conclusion(s): VILO reduced mortality at 28 to 60 days in severe COVID-19 pneumonia patients with no increase in infections suggesting the importance of targeting C5a while preserving MAC.

Longitudinal Dynamics of SARS-CoV-2 Spike-Specific Antibody Responses in Patients on Waiting List and after Lung Transplantation

Patients with end-stage lung diseases on the MHH waiting list for lung transplantation (LTx) have been vaccinated against the SARS-CoV-2 spike protein with usually three doses of the mRNA vaccine. Hence, they are supposed to develop robust antibody and T cell responses when immunized prior to LTx without the influence of immunosuppression. Therefore, we hypothesized the induction of high spike-specific IgG levels and protection against SARS-CoV-2 infection and severe COVID-19. To proof this, we aimed to analyze the IgG levels specific for the spike S1-, RBD- and S2-domains in patients on a waiting list (WL-LTx) longitudinally before and after their transplantation. Plasma obtained pre (n=70) and post LTx (n=28) of WL-LTx patients was analyzed for spike-specific IgG by Luminex-based multiplex assays. The threshold for positivity was set separately for each spike domain based on the median MFI +2σ in a healthy, unexposed pre-pandemic control group. Patients with previous SARS-CoV-2-infection were excluded. 95.7% of WL-LTx patients had seroconverted for either RBD-, S1- or S2-specific IgG pre LTx and still 92.86% were positive post LTx. Overall, S1-, S2- and RBD-specific IgG MFI values did not significantly differ between pre vs. post LTx. A subanalysis of matched plasma samples (n=25) revealed that 52% of the WL-LTx patients showed a higher IgG response pre than post LTx for all three spike protein domains and 28% showed even elevated antibody levels post LTx. Interestingly, S2-specific IgG MFI values were significantly elevated compared to RBD-specific IgG MFI values, both pre (S2 vs. RBD p<0.0001) and post LTx (S2 vs. RBD p=0.0225). The majority of WL-LTx patients mounted high SARS-CoV-2 spike-specific IgG responses following vaccination pre LTx. Based on the more efficient antibody production against the S2-domain compared to RBD- and S1-domains, S2-specific IgG responses should be included also in the general evaluation of humoral immune responses to SARS-CoV-2. As expected, WL-LTx patients showed a superior antibody response to vaccination compared to LTx-recipients vaccinated only after LTx, which could even be maintained after LTx in some patients. Therefore, both patients on waiting list and LTx recipients may benefit from additional booster vaccinations after LTx. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Antiviral T-cell frequencies in a healthy population: Reference values for evaluating antiviral immune cell profiles in immunocompromised patients and their application during the SARS-CoV-2 pandemic

Background: Viral infections and reactivations (e.g. cytomegalovirus (CMV)) are a major cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and in patients with immunodeficiencies. Here, antiviral drugs are the mainstay of treatment, but they have side effects and cannot achieve complete viral clearance without prior reconstitution of functional virus-specific T cells (VSTs). Method(s): We performed serological testing and measured VST frequencies against 23 viral protein-derived peptide pools of 11 clinically relevant human viruses by Interferon-gamma (IFN-gamma) ELISpot assay in a cohort of healthy donors (n=151). Moreover, we performed in-depth immune profiling in patients actively infected with SARS-CoV-2 (n=92) and in unvaccinated, recovered COVID-19 patients (n=204) by ELISA, ELISpot, multicolor flow cytometry and multiplex analysis. Result(s): Based on serological testing, IFN-gamma ELISpot results, age and sex, we established normal ranges for VST frequencies in healthy donors for better interpretation of VST frequencies observed in immunocompromised patients. While in SARS-CoV-2 recovered patients, the antiviral immune response was characterized by a broad specificity, significantly lower T-cell responses were observed during active infection. Comparison with the previously established reference values for VST frequencies revealed an overall reduced T-cell functionality based on the lack of CMV-pp65-reactive T cells in CMV-seropositive COVID-19 patients, which was associated with an inflammatory milieu, expression of inhibitory molecules, and effector caspase activity in T cells. Conclusion(s): The established reference values are an invaluable tool for immune response assessment, therapeutic agent intensity and decision making in immunocompromised patients. Further, we provide evidence that the low T-cell response observed during SARS-CoV-2 infection is not exclusively due to lymphopenia, but rather due to checkpoint- and cell death-associated mechanisms, suggesting that these patients may benefit from SARS-CoV-2-specific T-cell therapy.

Randomized, Controlled Phase 3 Study of anti-C5a Vilobelimab's Effect on Mortality in Critically Ill COVID-19 Patients: A Therapy for Viral Pneumonia

Background. SARS-CoV-2 induces endothelial damage and activates the complement system. In severe COVID-19 patients, complement split factor C5a is highly elevated leading to inflammation that contributes to multiorgan failure. The anti-C5a monoclonal antibody, Vilobelimab (Vilo), which preserves the membrane attack complex (MAC), was investigated in an adaptively designed, randomized doubleblind, placebo (P)-controlled Phase 3 international multicenter study for survival in critically ill COVID-19 patients (pts). Methods. COVID-19 pneumonia pts (N=368;Vilo n=177, P n=191), mechanically ventilated within 48 hrs before treatment, received up to 6, 800 mg infusions of Vilo or P on top of standard of care. The primary and main secondary endpoints were 28-day (d) and 60-d all-cause mortality. Results. Pts enrolled in the study were on corticosteroids (97%) and anticoagulants (98%) as standard of care. A smaller proportion (20%) were either continuing or had taken immunomodulators such as tocilizumab and baricitinib prior to receiving Vilo. The 28-d all-cause mortality was 31.7% with Vilo vs 41.6% with P (Kaplan-Meier estimates;Cox regression site-stratified, HR 0.73;95% CI:0.50-1.06;P=0.094), representing a 23.8% relative mortality reduction. In predefined primary outcome analysis without site stratification, however, Vilo significantly reduced mortality at 28 (HR 0.67;95% CI:0.48-0.96;P=0.027) and 60 days (HR 0.67;95% CI:0.48-0.92;P=0.016). Vilo also significantly reduced 28-d mortality in more severe pts with baseline WHO ordinal scale score of 7 (n=237, HR 0.62;95% CI:0.40-0.95;P=0.028), severe ARDS/PaO2/FiO2 <= 100 mmHg (n=98, HR 0.55;95% CI:0.30-0.98;P=0.044) and eGFR < 60 mL/min/1.73m2 (n=108, HR 0.55;95% CI:0.31-0.96;P=0.036). Treatment-emergent AEs were 90.9% Vilo vs 91.0% P. Infections were comparable: Vilo 62.9%, P 59.3%. Infection incidence per 100 Pt days were equal. No meningococcal infections were reported. Serious AEs were 58.9% Vilo, 63.5% P. Conclusion. Vilo significantly reduced mortality at 28 and 60 days in critically ill COVID-19 pts with no increase in infections suggesting the importance of targeting C5a while preserving MAC. Vilo targets inflammation which may represent an approach to treat sepsis and ARDS caused by other respiratory viruses. (Figure Presented).

Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline.

Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.