Early studies suggest that up to 67 per cent of hospitalised COVID-19 patients may present with additional organ dysfunction syndromes, other than lungs that may be induced by high level of circulating cytokines
Cytokine Storm appears to be common in severe cases of COVID-19. This is an umbrella term wherein a massive release of cytokines; i.e. immune proteins that may lead to multi-organ involvement. This uncontrolled reaction can occur in a variety of conditions, including infections, organ damage and autoimmune disorders. Cytokine Storm can be life-threatening and may require urgent intervention. Early studies suggest that up to 67 per cent of hospitalised COVID-19 patients may present with additional organ dysfunction syndromes, other than lungs that may be induced by a high level of circulating cytokines. [1]
Dr Rajesh Pandey, Intensivist, BLK, Delhi said. “According to Chinese researchers with much experience of managing COVID-19 patients, Continuous Renal Replacement Therapy (CRRT) is not just renal support, but also helps in curbing the cytokine storm and multi-organ support in critically ill patients. [5] In situations where patients may not be able to sustain rapid changes in body fluid balance and metabolic fluctuations and in situations where other extracorporeal therapies are required like invasive ventilator support, continuous RRT can be used as an integrated system and are preferred over parallel systems, as was highlighted by a small retrospective study in COVID-19 patients requiring invasive mechanical ventilation, where CRRT was associated with a significant reduction in mortality (74.6 per cent vs 54.5 per cent p=0.032) than those treated without CRRT. [6] “Given that many of COVID-19 patients may have multi-organ dysfunction or failure CRRT might be a better option for patients on multiple extracorporeal therapies.”
“As per the recommendation of American Society of Nephrology and in the COVID-19 pandemic scenario, the CRRT may be one of the preferred modalities, especially for those who have haemodynamic instability. CRRT is a blood purification therapy applied for 24 hours a day. At present, among the other therapies being used, CRRT is beneficial to maintain volume balance, haemodynamic stability and to improve the clearance efficiency of middle-sized molecules such as cytokines especially when used with adsorptive filters which can help with improved clearance of cytokines from circulation”, [7] said Dr Deepak Govil, Intensivist, Medanta.
He further added, “One such adsorptive filter available in India is Oxiris, which amidst COVID-19 pandemic crisis has also received emergency use authorisation from the US Food and Drug Administration (FDA) for COVID-19 treatment, moreover the use of this filter can provide multiple blood purification therapies simultaneously, including cytokine removal or / and CRRT.”
In addition to the above-mentioned benefits, Chinese researchers recommend CRRT treatment should also be used in other non-renal indications, especially to control cytokine storm, appropriate early intervention should be made when ARDS, right heart failure and capacity overload occurs at the initial stage, CRRT should be activated to implement three-level management capacity to better support cardiopulmonary function. [8] Overall, along with ventilators the hospitals should also plan and manage adequate supply for dialysis equipment and associated supplies not only for outpatient use but also critically ill patients in intensive care units.
References:
- Ronco C, Reis T, De Rosa S. Coronavirus epidemic and extracorporeal therapies in intensive care: si Vis pacem para bellum [published online ahead of print, 2020 Mar 13]. Blood Purif. 2020; 1–4. doi:10.1159/000507039
- https://www.asn-online.org/ntds/resources/Webcast_2020_04_21_AKI!NOW.mp4
- Chinese Medical Association, Expert consensus on the Application of Special Blood purification Technology in severe COVID-19 Pneumonia Branch of Nephrology, Chinese Medical Association Professional Committee of Nephrology, Chinese Research Hospital Association
- Yi Yang*, Jia Shi*, Shuwang Ge et al. Effect of continuous renal replacement therapy on all cause mortality in COVID-19 patients undergoing invasive mechanical ventilation: a retrospective cohort study. https://doi.org/10.1101/2020.03.16.20036780
- Chinese Medical Association, Expert consensus on the Application of Special Blood purification Technology in severe COVID-19 Pneumonia Branch of Nephrology, Chinese Medical Association Professional Committee of Nephrology, Chinese Research Hospital Association
- Chinese Medical Association, Expert consensuxs on the Application of Special Blood purification Technology in severe COVID-19 Pneumonia Branch of Nephrology, Chinese Medical Association Professional Committee of Nephrology, Chinese Research Hospital Association