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Critical Care
Erschienen in: Critical Care 1/2020

Open Access 10.08.2020 | COVID-19 | Research Letter

Therapeutic plasma exchange in patients with COVID-19 pneumonia in intensive care unit: a retrospective study

verfasst von: Bulent Gucyetmez, Hakan Korkut Atalan, Ibrahim Sertdemir, Ulkem Cakir, Lutfi Telci, COVID-19 Study Group

Erschienen in: Critical Care | Ausgabe 1/2020

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A comment to this article is available online at https://​doi.​org/​10.​1186/​s13054-020-03309-3.

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Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
In patients with COVID-19 pneumonia, high risk of thrombosis became a current issue, and d-dimer levels indicating fibrin degradation products (FDPs) in the plasma were found as a predictor for mortality [1, 2]. Although unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) decrease the production of FDPs by inhibiting factors Xa and II, they cannot contribute metabolization of existing FDPs. Furthermore, FDPs cannot be filtered by known cytokine filters because of their molecular weight (minimum 240 kDa) [3, 4]. Yet, FDPs can be removed by therapeutic plasma exchange (TPE) [5]. Therefore, recently, three consecutive TPE sessions were performed in selected patients with COVID-19 pneumonia in intensive care units (ICUs) after the assessment of their clinical and coagulation status. In the study, the effect of TPE on outcomes was retrospectively investigated in patients with COVID-19 pneumonia.
All COVID-19 patients admitted to 5 different tertiary ICUs between 10 March and 10 May 2020 were evaluated, and 73 of 91 patients were included in the study. The patients who died within the first 4 days and who were still in the ICUs on 10 May were excluded. According to the Turkish Health Minister Algorithm for COVID-19, all included patients received the same antiviral (favipiravir, hydroxychloroquine, azithromycin) therapy and anticoagulant prophylaxis (UFH infusion 100 mcg/kg or LMWH 0.01 mL/kg). Since two different protocols were used in 5 ICUs, patients with d-dimer ≥ 2 in 3 ICUs had only received therapeutic anticoagulation whereas patients with d-dimer ≥ 2 in the other 2 ICUs had received TPE plus therapeutic anticoagulation. In all ICUs, for all patients in GII, echocardiography, lower extremity venous Doppler, and, if pulmonary thrombosis suspected, thorax computerized tomography angiography were performed. After collecting data, 73 patients were divided into 2 groups as group I (GI) (d-dimer < 2 mg/L) and group II (GII) (d-dimer ≥ 2 mg/L), and then GII was also divided into 2 groups as GIIa (TPE+) and GIIb (TPE−). Patients’ characteristics, respiratory and laboratory parameters, and outcomes were recorded. Propensity score matching (PSM) analysis was conducted on R v4.0.1 (0.2 caliper without replacement and nearest neighbor model, 1:1 ratio) by using 14 covariates (age, gender, CCI, APACHE II, SOFA score, lactate, leucocyte, lymphocyte, d-dimer and creatinine at the ICU admission, maximum respiratory support, the usage of steroid, IL-6 blocker, and cytokine filter).
The total mortality rate was 27.4%. Mortality rates of GI and GII were 5% and 35.9%, respectively. In GII, major thromboembolic events were not detected in any patients. The median (min-max) day for the starting TPE was 3 (2–4). In GIIa, APACHE II, SOFA scores, d-dimer and interleukin-6 (IL-6) levels at the ICU admission, and length of ICU stay were significantly higher than those of GI whereas mortality rates were similar in those groups (Table 1). The median values of the LOS-ICU in survivors and non-survivors in GII were 14 (6.5–21.5) and 15.5 (8–23), respectively (p = 0.630). In GIIa, lactate dehydrogenase (LDH), d-dimer, ferritin, IL-6, C-reactive protein (CRP), and procalcitonin levels were significantly decreased after three consecutive TPEs (Table 2). Furthermore, although ferritin level at the ICU admission was higher in GIIa, the mortality rate in both before and after PSM was higher in GIIb (45.7% and 58.3%) than in GIIa (16.7% and 8.3%) (p = 0.037, p = 0.009, respectively) (Table 1).
Table 1
Comparisons of patients groups
 
GI (d-dimer < 2) (n = 20)
GII (d-dimer ≥ 2)
Before PSM
After PSM
GIIa (TPE+) (n = 18)
GIIb (TPE−) (n = 35)
p1 (GI and GIIa)
p2 (GIIa and GIIb)
GIIa (TPE+) (n = 12)
GIIb (TPE−) (n = 12)
p2 (GIIa and GIIb)
Age (years)
60 ± 14
62 ± 12
62 ± 15
0.615
0.951
61 ± 14
64 ± 17
0.605
Male, n (%)
13 (65.0)
14 (77.8)
26 (74.3)
0.386
0.780
8 (66.7)
8 (66.7)
1.000
BMI (kg/m2)
27.3 (5.8)
27.9 (5.5)
27.3 (6.6)
0.290
0.237
28.5 (6.1)
25.0 (6.6)
0.078
CCI
2.5 (4)
3 (3)
4 (3)
0.919
0.422
3.0 ± 2.2
3.8 ± 1.7
0.270
At the ICU admission
 APACHE II
12 ± 4
17 ± 4
17 ± 5
0.002
0.886
17 ± 3.3
17.5 ± 5.6
0.794
 SOFA Score
5 (3)
6 (1)
7 (3)
0.002
0.223
6 (2)
6 (2)
0.713
 PaO2/FiO2 ratio
128 (68)
97 (51)
113 (79)
0.251
0.229
108 (106)
125 (103)
0.551
 SpO2 (%)
89 (5)
91 (7)
89 (5)
0.377
0.597
92 (10)
91 (5)
0.590
 Lactate (mmol/L)
1.4 (0.6)
1.4 (0.7)
1.4 (0.9)
0.988
0.631
1.5 (0.8)
1.3 (0.5)
0.291
 WBC (×103/μL)
9.6 (3.9)
6.9 (6.4)
8.2 (6.5)
0.573
0.353
8.7 ± 4.9
7.4 ± 2.7
0.430
 Lymc (×103/μL)
0.82 ± 0.40
0.80 ± 0.34
0.89 ± 0.42
0.553
0.271
0.83 ± 0.3
0.82 ± 0.5
0.963
 d-dimer (mg/L)&
1.2 (0.3–1.9)
5.0 (2.1–35.2)
7.2 (2.1–35.5)
< 0.001
0.151
4.5 (2.1–35.2)
6.0 (2.2–32.2)
0.514
 Ferritin (ng/mL)
1015 (1735)
1735 (1853)
900 (1454)
0.158
0.018
1742 (2117)
605 (1346)
0.012
 IL-6 (pg/mL)&
28.3 (5.3–1418)(8)
134 (36.2–2958)(13)
254 (33–5233)(13)
0.036
0.101
155 (39.6–2958)(8)
237 (33–4885)(4)
0.933
 CRP (mg/dL)
18.6 ± 10.9
22.2 ± 12.1
27.8 ± 10.4
0.340
0.086
19.2 ± 10.3
24.0 ± 11.0
0.275
 Creatinine (mg/dL)
0.88 (0.29)
0.87 (0.37)
0.99 (0.82)
0.874
0.051
0.91 ± 0.3
0.90 ± 0.3
0.944
 Urea (mg/dL)
28 (29)
32 (19)
36 (26)
0.942
0.288
28 (32)
35 (14)
0.291
 Number of damaged lobes, n (%)&
3 (2–4)
3 (2–5)
3 (2–5)
0.149
0.118
3 (2–5)
3 (3–5)
0.671
In the first 48 h
 Breath rate/min (max)
34 (6)
33 (9)
33 (5)
0.988
0.713
33 (11)
33 (5)
0.590
 PaO2/FiO2 ratio (min)
117 ± 42
98 ± 30
105 ± 34
0.087
0.376
104 ± 32.4
120 ± 32.5
0.235
 FiO2 (%) (max)
75 (48)
80 (30)
80 (35)
0.082
0.969
80 (25)
80 (30)
0.799
 PEEP (cmH2O) (max)
12 (6)
12 (4)
14 (4)
0.502
0.056
12.0 ± 2.3
13.0 ± 1.9
0.215
 Cdyn (ml/cmH2O) (min)
44 (6)
37 (12)
41 (8)
0.003
0.058
36.3 ± 6.6
39.5 ± 7.0
0.265
In the first week
 WBC (×103/μL) (max)
13.2 (5.8)
11.0 (8.9)
12.6 (6.6)
0.077
0.086
10.4 (10.3)
11.0 (6.7)
0.590
 WBC (×103/μL) (min)
5.9 (2)
6.3 (4)
4.9 (4)
0.718
0.612
6.7 (4.4)
4.6 (1.5)
0.219
 Lymc (×103/μL) (min)
0.48 (0.40)
0.5 (0.28)
0.49 (0.46)
0.919
0.573
0.52 (0.29)
0.45 (0.28)
0.551
 NLCR (max)
16.4 (16.2)
15 (8)
11 (11)
0.460
0.517
13.6 (10.1)
11.6 (11.5)
0.843
 Lactate (mmol/L) (max)
2.1 (0.7)
2.4 (1.1)
2.4 (0.8)
0.087
0.955
2.3 (1.0)
2.4 (1.6)
0.347
 Fluid balance (mL)
3670 (3198)
4552 (2973)
3849 (2196)
0.874
0.441
4174 ± 2907
5331 ± 3170
0.361
 Total fluid (mL/kg/day)
40.7 (9.3)
44.3 (15.5)
44.8 (11)
0.696
0.910
44.8 ± 13.5
48.7 ± 12.0
0.460
Respiratory support (max), n (%)
 IMV
13 (65.0)
16 (88.8)
30 (85.7)
0.084
0.746
11 (91.7)
12 (100)
0.307
 NIMV
3 (15.0)
1 (5.6)
3 (8.6)
0.344
0.694
1 (8.3)
0
0.307
 HFOT
4 (20.0)
1 (5.6)
2 (5.7)
0.188
0.981
0
0
NA
Additional therapies, n (%)
        
 Cytokine filters
1 (5.0)
3 (16.7)
3 (8.1)
0.427
0.434
2 (16.7)
1 (8.3)
0.592
 IL-6 blocker
12 (60.0)
9 (50.0)
20 (57.1)
0.536
0.621
7 (58.3)
6 (50)
0.682
 Steroids
11 (55.0)
10 (55.6)
20 (57.1)
0.357
0.912
7 (58.3)
7 (58.3)
1.000
 Duration of IMV (h)&
168 (0–816)
286 (0–1008)
192 (0–720)
0.1 12
0.067
316 ± 271
278 ± 139
0.671
 AKI, n (%)
7 (35.0)
6 (33.3)
19 (54.3)
0.914
0.148
3 (25)
6 (50)
0.206
 Tracheotomized patients, n (%)
2 (10.0)
2 (11.1)
1 (2.9)
0.911
0.218
1 (8.3)
0 (0)
0.307
 LOS-ICU, (days)&
12 (6–34)
20 (5–42)
11 (7–35)
0.017
0.003
20 ± 10
14 ± 5
0.067
 Mortality, n (%)
1 (5.0)
3 (16.7)
16 (45.7)
0.242
0.037
1 (8.3)
7 (58.3)
0.009
AKI acute kidney injury, APACHE II Acute Physiology and Chronic Health Evaluation, BMI body mass index, CCI Charlson comorbidity index, Cdyn dynamic compliance, CRP C-reactive protein, HFOT high-flow oxygen therapy, ICU intensive care unit, IL-6 interleukin-6, IMV invasive mechanical ventilation, LOS length of stay, Lymc lymphocyte count, NIMV non-invasive mechanical ventilation, NLCR neutrophil-lymphocyte count ratio, PSM propensity score matching, SOFA, sequential organ failure assessment, TPE therapeutic plasma exchange, WBC white blood cell. Results were given as percentage, mean ± sd, and median (IQR or min-max). &Minimum and maximum values. Student t and Mann-Whitney U tests were used for statistical analysis
Table 2
Comparisons of laboratory parameters in pre and post-TPE procedure
 
Pre-TPE
Post-TPE
p
WBC (× 103/μL)
9.08 ± 4.1
9.14 ± 3.5
0.951
Neuc (×103/μL)
7.38 ± 3.1
7.33 ± 3.3
0.953
Lymc (× 103/μL)
0.9 (0.5–1.3)
1.02 (0.77–1.27)
0.053
NLCR
6.8 (1.8–11.7)
6.7 (4.2–9.2)
0.184
LDH (IU/L)
436 (322–550)
239 (181–297)
0.001
d-dimer (mg/L)&
7.8 (2.1–35.2)
1.3 (0.6–3.9)
< 0.001
Ferritin (ng/mL)&
1268 (399–6110)
405 (157–1650)
0.001
IL-6 (pq/mL)(13)&
161 (36.2–2958)
24.5 (1.5–130)
0.001
CRP (mg/dL)&
11.8 (0.4–29.7)
0.9 (0.3–7.2)
< 0.001
Procalcitonin (ng/mL)&
0.27 (0.02–87)
0.1 (0.01–39)
0.002
CRP C-reactive protein, IL-6 interleukin-6, LDH lactate dehydrogenase, Lymc lymphocyte count, Neuc neutrophil count, NLCR neutrophil-lymphocyte count ratio, TPE therapeutic plasma exchange, WBC white blood cell. Results were given as percentage, mean ± sd, and median (quartiles or min-max). &Minimum and maximum values. Paired sample and Wilcoxon tests were used for the statistical analysis
Some patients with COVID-19 pneumonia have a high risk of thrombosis leading to worse outcomes. Therefore, monitoring d-dimer levels is crucial. In these groups of patients, TPE seems to be a treatment which may improve outcomes by effectively removing FDPs and restoring coagulation status. We are aware that TPE may not be routinely required in these patients [6]. However, we think that it should be featured as a part of the treatment especially in COVID-19 pneumonia patients with a high risk of thrombosis.

Acknowledgements

We would like to express our gratitude to our nurses who have taken care of the patients and performed TPE procedure in the ICU and COVID-19 Study Group. COVID-19 Group collaborating authors: Aylin Ogan2, Aylin Cimet Ayyildiz2, Berrin Yalcin2, Behiye Oren6, Fadıl Havas6, Sevda Dizi6, Birsen Kose6, Umran Yakici6, Cenk Sahan6, Elif Ozkilitci6, Ugur Tunali6, Deniz Gunes7, Ozlem Dincer7, Reyhan Sahin7, Duran Ozdemir7, Mehtap Selcuk8, Ceyhun Solakoglu8, Unsal Arif Turan8, Erkan Kaya8, Mustafa Emre Kavlak3, Pelin Katar3, Hande Aygun9, Kerim Cikim10, Ozkan Uysal10, Nur Ozturk Kaskir11, Aysun Soylu12.
2General Intensive Care Unit, Acibadem International Hospital, Istanbul, Turkey
3General Intensive Care Unit, Memorial Atasehir Hospital, Istanbul, Turkey
6General Intensive Care Unit, Acibadem Atakent Hospital, Istanbul, Turkey
7General Intensive Care Unit, Acibadem Bakirkoy Hospital, Istanbul, Turkey
8General Intensive Care Unit, Acibadem Kadikoy Hospital, Istanbul, Turkey
9Department of Infection Disease and Clinical Microbiology, Acibadem International Hospital, Istanbul, Turkey
10Department of Internal Medicine, Acibadem International Hospital, Istanbul, Turkey
11Department of Chest Disease, Acibadem International Hospital, Istanbul, Turkey
12Department of Biochemistry, Acibadem International Hospital, Istanbul, Turkey
The study was approved by The Scientific Committee of the Turkish Health Ministry (2020-05-11T22_01_29).
No applicable

Competing interests

The authors declare that they have no competing interests.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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Literatur
1.
Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46:1089–98.
2.
Zhang L, Yan X, Fan Q, Liu H, Liu X, Liu Z, et al. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19. J Thromb Haemost. 2020;18:1324–9.
3.
Diab M, Platzer S, Guenther A, Sponholz C, Scherag A, Lehmann T, Velichkov I, Hagel S, Bauer M, Brunkhorst FM, et al. Assessing efficacy of CytoSorb haemoadsorber for prevention of organ dysfunction in cardiac surgery patients with infective endocarditis: REMOVE-protocol for randomised controlled trial. BMJ Open. 2020;10(3):e031912.CrossRef
4.
Walker JB, Nesheim ME. The molecular weights, mass distribution, chain composition, and structure of soluble fibrin degradation products released from a fibrin clot perfused with plasmin. J Biol Chem. 1999;274(8):5201–12.CrossRef
5.
Rimmer E, Houston BL, Kumar A, Abou-Setta AM, Friesen C, Marshall JC, Rock G, Turgeon AF, Cook DJ, Houston DS, et al. The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. Crit Care. 2014;18(6):699.CrossRef
6.
Honore PM, Mugisha A, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Therapeutic plasma exchange as a routine therapy in septic shock and as an experimental treatment for COVID-19: we are not sure. Crit Care. 2020;24(1):226.CrossRef
Metadaten
Titel
Therapeutic plasma exchange in patients with COVID-19 pneumonia in intensive care unit: a retrospective study
verfasst von
Bulent Gucyetmez
Hakan Korkut Atalan
Ibrahim Sertdemir
Ulkem Cakir
Lutfi Telci
COVID-19 Study Group
Publikationsdatum
10.08.2020
Verlag
BioMed Central
Schlagwort
COVID-19
Erschienen in
Critical Care / Ausgabe 1/2020
Elektronische ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-020-03215-8

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