Extracorporeal cytokine reduction using oxiris blood purification in COVID-19

ABSTRACT

Introduction: Severe COVID-19 infection can cause 'cytokine storm' and endorgan dysfunction. OXIRIS, a blood-purification filter, was recently approved by the FDA under emergency use authorization for this indication due to its ability to remove cytokines and endotoxin through its AN-69ST membrane. We describe our experience with the first two cases treated at our institution. Case Description Case 1 58 year-old female patient with a baseline creatinine of 0.8 mg/dL & history of hemoglobin SC disease was admitted with respiratory failure due to COVID-19 infection. She deteriorated on hospital day (HD) 6 and was intubated. She received broad-spectrum antibiotics and convalescent plasma. On HD 15 she had increasing vasopressor requirement, anuric AKI and was started on continuous renal replacement therapy (CRRT). Due to worsening clinical status on HD18 she was started on the OXIRIS hemofilter through the CRRT circuit for 48 hours. Oxygenation improved and there was some improvement in inflammatory markers (IM) (table 1), however, the family withdrew care on HD 20. Case 2 29-year-old male with no prior past medical history apart from morbid obesity presented with fever and dry cough in the setting of recent COVID-19 exposure. He was found to be COVID-19 positive and rapidly deteriorated with resultant intubation on HD4. He received hydroxychloroquine, doxycycline, remdesivir and convalescent plasma. OXIRIS hemoperfusion was initiated on HD8 due to worsening hypoxia despite high FiO2. Oxygenation improved by HD10 (table 1) and he was successfully extubated on HD16. Discussion: We present our first 2 cases using the OXIRIS hemofilter. We treated the patients for 48 hours with a scheduled filter exchange at 24 hours. We used a blood flow of 250 ml/min and dialysate flow of 25 ml/kg/hour with either systemic heparin or regional citrate anticoagulation along with 1L/hr of pre-filter saline. For hemoperfusion we used the same parameters without dialysate. We observed rapid improvements in oxygenation (Figure 1). The findings are hypothesis generating though more data is needed to determine optimal timing and efficacy of this filter.