Abstract
Cytokine storm syndrome (CSS) has been documented in coronavirus disease 2019 (COVID-19) since the first reports of this disease. In the absence of vaccines or direct therapy for COVID-19, extracorporeal blood treatment (EBT) could represent an option for the removal of cytokines and may be beneficial to improve the clinical outcome of critically ill patients. Intermittent haemodialysis (IHD), using high flux (HF) or high cut-off membranes, and continuous renal replacement therapy (CRRT) could be used for blood purification in COVID-19 patients with CSS. To the best of our knowledge, cytokine kinetics during and after different types of EBT on COVID-19 patients have never been studied. In this study, we describe cytokine variation and removal during and after IHD and CRRT in COVID-19 patients with acute kidney injury (AKI). Methods: Patients with COVID-19-related AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria and admitted at Intensive Care Unit (ICU) were studied. Blood samples were collected at the start and end of both IHD using HF membranes (10 patients) and continuous venovenous haemodiafiltration (CVVHDF: 10 patients) in two sessions for measuring 13 different plasma interleukins and calculating the cytokine removal rate. Results: We evaluated cytokine removal in patients with COVID-19-related AKI undergoing either prolonged IHD (10 patients) or CRRT (CVVHDF: 10 patients). There was no difference between the IHD and CVVHDF groups regarding mechanical ventilation, vasoactive drug use, age or prognostic scores. Patients treated by CRRT presented higher levels of IL-2 and IL-8 than patients treated by prolonged IHD at the start of dialysis. Cytokine removal ranged from 9–78%. Patients treated by CRRT presented higher cytokine removal rates than those treated by prolonged IHD for IL-2, IL-6 IL-8, IP-10 and TNF. The removal rates of IL-4, IL-10, IL-1β, IL-17A, IFN, MCP-1 and free active TGF-B1 were similar in the two groups. After one session of CVVHDF (24 h) the IL-2 and IL-1β levels did not vary significantly, whereas IL-4, IL-6, IL-8, IL-10, IL-17A, TNF, IFN, IP-10, MCP-1, IL-12p70 and free active TGF-B1 decreased by 33.8–76%, and this decrease was maintained over the next 24 h. In the prolonged IHD groups, IL-2, IL-6, TNF, IP-10 and IL-1β levels did not decrease significantly whereas IL-4, IL-8, IL-10, IL-17A, IFN, MCP-1, IL-12p70 and free active TGF-B1 decreased by 21.8–72%. However, all cytokine levels returned to their initial values after 24 h, despite their removal. Conclusions: Cytokine removal is lower using prolonged IHD with HF membranes than by using CVVHDF, and IHD allows a transient and selective decrease in cytokines that can be correlated with mortality during CSS-related COVID-19.