Case series and reports

Effect of extracorporeal cytokine removal on vascular barrier function in a septic shock patient

David S, Thamm K, Schmidt BM, Falk CS, Kielstein JT
J Intensive Care 2017; 5: 12

A 32-year-old female presented with septic shock and accompanying acute kidney injury to ICU. In...

A 32-year-old female presented with septic shock and accompanying acute kidney injury to ICU. In spite of a broad anti-infective regimen, adequate fluid resuscitation, and high doses of inotropics and catecholamines, she remained in refractory hypotensive shock. The extraordinary severity of septic shock suggested an immense overwhelming host response assumingly accompanied by a notable cytokine storm. Thus, a CytoSorb adsorber was added to the dialysis circuit. To analyze the endothelial phenotype in vitro before and after extracorporeal cytokine removal, the authors tested the patient’s serum on human umbilical vein endothelial cells (HUVECs) and the effect on the endothelial integrity was assessed. The authors found severe alterations in cell-cell contacts, the cytoskeletal architecture, and profound functional permeability changes (in other words clinical vascular leakage syndrome) when blood from the patient taken prior to the CytoSorb adsorber was added to the HUVECs. However, the endothelial barrier was protected from these profound adverse effects when blood serum was collected after the CytoSorb adsorber (cytokine removal) and added to the HUVECs. In conclusion the benefit of extracorporeal cytokine removal with CytoSorb in septic shock patients might-at least in part-be promoted via protection of vascular barrier function.

Application of Hemoadsorption in a Case of Liver Cirrhosis and Alcohol-Related Steatohepatitis with Preexisting Hepatitis C Infection.

Buttner S, Patyna S, Koch B, Finkelmeier F, Geiger H, Sarrazin C, Farnik H.
Blood Purif 2017; 44(1): 30-31

This is the first case study that confirms the successful direct removal of liver toxins...

This is the first case study that confirms the successful direct removal of liver toxins, including ammonia and bile acids by the CytoSorb. In this report a 36-year-old patient with chronic viral hepatitis C and long term chronic alcohol abuse was admitted to ICU with decompensated ethanol toxic liver cirrhosis. Despite an initial attempt to stabilize the patient using an albumin infusion and multiple paracenteses the patient developed hepatorenal syndrome and subsequent dialysis dependency. During this time, an evaluation as to whether the patient could be listed for a liver transplantation was rejected.  As a „last resort“ therapy, CytoSorb treatment was initiated with the rationale to remove inflammation-triggering factors and liver toxins (bile acids, bilirubin, ammonia) in the context of his systemic inflammatory condition as well as his acute-on-chronic liver failure. In total two treatments with CytoSorb were carried out for 6 hours each with a treatment pause of 5 days between adsorbers due to non-existent evidence of use in this kind of patient. Pre and post adsorber measurements during the second treatment confirmed efficient removal of ammonia, bilirubin and bile acids. After initially recovering well with planned discharge to his home environment, the patient subsequently developed a nosocomial pneumonia, after which the patient went into another episode of fulminant pneumogenic sepsis and died three weeks after the last CytoSorb treatment. In this case report, the treatment with combination of CRRT and hemoadsorption using CytoSorb worked extremely well and effectively as a liver support. As a consequence, hepatic encephalopathy improved significantly due to efficient removal of liver toxins including ammonia.

Rescue of cytokine storm due to HLH by hemoadsorption in a CTLA4-deficient patient

Greil C, Roether F, La Rosée P, Grimbacher B, Duerschmied D, Warnatz K
Journal of Clinical Immunology 2017; epub

In this letter to the editor the authors describe the use of a CytoSorb in...

In this letter to the editor the authors describe the use of a CytoSorb in a patient with secondary hemophagocytic lymphohistiocytes (HLH) caused by CTLA-4 deficiency. CTLA-4 deficiency is caused by a heterozygous germ line mutation of the cytotoxic T lymphocytic antigen-4 (CTLA-4) gene leading to a syndrome with prominent features of immune dysregulation. HLH is characterized by fever, splenomegaly, bicytopenia, highly elevated serum levels of ferritin and soluble interleukin-2 receptor (sIL2-R), decreased natural killer (NK) cell activity, hypertriglyceridemia and detection of hemophagocytosis in bone marrow or other tissue. To date, HLH has never been described in a patient with CTLA-4 deficiency. A 50 yr old patient was admitted to ICU with SIRS and multi-organ failure. Despite aggressive intervention his clinical condition rapidly worsened so a CytoSorb adsorber was added into the circuit of the hemodiafiltration. In total 4 adsorbers were used, with columns being changed every 24 hrs. Cytokine adsorption resulted in an immediate decrease in inflammatory parameters, the clinical condition improved in parallel. This suggests the CytoSorb was the decisive therapeutic intervention in this case. The patient was discharged to the regular ward nine days after CytoSorb initiation.

Hemadsorption with Adult CytoSorb(R) in a Low Weight Pediatric Case.

Cirstoveanu CG, Barascu I, Mc Kenzie Stancu S
Case Rep Crit Care 2017: 6987167

This case study describes a nine-month old male infant admitted to the Neonatal Intensive Care...

This case study describes a nine-month old male infant admitted to the Neonatal Intensive Care Unit due to sepsis post cardiac surgery (Fallot tetralogy), and multi-system organ failure (MSOF), including liver and renal failure which was successfully treated by a combination of continuous hemodiafiltration (HDF) and hemoadsorption with CytoSorb®. CytoSorb added to the set up on day 9 due to increasing bilirubin levels. Over the 49 hour period of hemoadsorption plus CytoSorb, total bilirubin decreased from 54 to 14 mg/dl, the patient’s general status improved considerably, accompanied by a rapid decrease in his liver enzymes (aminotransferases). Hemodynamic status also improved and requirement for inotropes decreased rapidly during the two days of CytoSorb treatment. The patient was discharged home after 34 days of hospitalization, in good general health. This is the first published case of the successful use of CytoSorb treatment in such a young patient (9 months old, 9 kilos in weight).

(The Use of a Cytokine Adsorber (CytoSorb) in a Patient with Septic Shock and Multi-Organ Dysfunction (MODS) after a Severe Burn Injury)

Houschyar KS, Nietzschmann I, Siemers F
Handchir Mikrochir Plast Chir 2016; epub

Article in German only

This case report reports on a 21-year-old patient who was admitted...

Article in German only

This case report reports on a 21-year-old patient who was admitted to hospital immediately following an explosion in the home environment with 2b-3-degree burns of a total of 60% of the body surface area. On the day of admission, he was immediately given bath therapy while he was still hemodynamically stable, with surgical wound treatment of the burned areas. Because of the severity of his burns, multiple operations were performed, with Meek transplants 1: 6 on his lower abdomen, both upper arms, the upper thorax and both forearms. Further therapy consisted of epifascial debridements, keratinocyte deposits and automatic prone / supine positioning. With sustained elevation of the inflammatory parameters (leukocytes, C-reactive protein and procalcitonin) and renal function, positive blood cultures and wound smears for Acinetobacter baumannii, the decision was made to start hemofiltration therapy with additional CytoSorb adsorbers to induce a reduction in these parameters. The CytoSorb adsorber was used daily from the 9th – 17th treatment days and from days 32 – 52. The interleukins IL-6 and IL-10 were significantly reduced during the treatment, the catecholamine requirement was significantly reduced and circulatory stabilization could be achieved. Due to cardiopulmonary insufficiency in the context of a multiorgan failure, the patient died on the 52nd postoperative day.

Hybrid blood purification strategy in pediatric septic shock

Bottari G, Taccone FS, Moscatelli A
Crit Care 20(1): 366

In this letter to the editor, the case of a 12 year old girl with...

In this letter to the editor, the case of a 12 year old girl with a history of acute lymphatic leukemia and recent chemotherapy admitted to the ED with fever and fatigue is described (cause of which later found to be klebsiella pneumonia from a central line infection). She was give fluid resuscitation, empiric antibiotics and admitted to ICU. Because of ongoing hypotension, epinephrine and norepinephrine were initiated, however she remained severely hypotensive. Continuous renal replacement therapy was started with a high cut off filter (Septex) along with a CytoSorb adsorber. After 48 hours a significant reduction in the vasopressors was observed, lactate decreased as did procalcitonin. The ‘hybrid’ extracorporeal blood purification – EBP (combination of CtoSorb and Septex) was continued for 72 hours in total and the patient could be discharged after 10 days. No adverse events related to the blood purification procedure were observed. The authors state that the Literature list CytoSorb® 10 November 2016 combination of ‘hybrid’ EBP might have a synergistic effect in the setting of pediatric septic shock.

A clinical experience of using extracorporeal cytokine adsorption device (CytoSorb) in a case of Dengue fever

Khan, Z.A.
J Evid. Based Med. Healthc., 3(87): 4779 - 81

This case study reports on a patient with Dengue fever, septic shock and multiple organ...

This case study reports on a patient with Dengue fever, septic shock and multiple organ failure (MOF). Dengue is a mosquito-borne viral disease where it is thought that elevated cytokines (tumour necrosis factor alpha – TNF-α, interleukins and interferon gamma – IFN-γ) cause damage to the endothelial cells of the capillaries that results in fluid leakage. Here a 32 year old male patient was admitted to the intensive care unit and because of multiple organ failure, he was mechanically ventilated and put on renal replacement therapy. CytoSorb was used as an adjuvant supportive therapy on days 2, 4 and 6 of admission. The patient also received multiple transfusions to address thrombocytopenia and coagulopathy. The patient showed gradual improvement with a normalization of the central nervous system, improved oxygenation status, adequate renal function and normal platelet count (APACHE score 27 before and 12 at the end of CytoSorb treatment). Liver function also improved significantly. Serum Glutamic Oxaloacetic Transaminase – GOT (AST) fell from 15,690 U/L to 156 U/L, and Serum Glutamic Pyretic Transaminase – GPT (ALT) fell from 3910 to 84 after CytoSorb treatment). The patient was discharged from ICU on day 13 and subsequently discharged. The authors note that CytoSorb® seems to be a useful and safe extracorporeal therapy option to stabilize and help dengue shock patients with MODS to recover.

Can cytokine adsorber treatment affect antibiotic concentrations? Acase report.

Zoller M, Döbbeler G, Maier B, Vogeser M, Frey L, Zander J
J AntimicrobChemother. 2015 Jul;70(7):2169-71

This case study reports on a patient with an excessive inflammatory response, septic shock and...

This case study reports on a patient with an excessive inflammatory response, septic shock and MOF who was admitted to the ICU. Initial laparotomy revealed an ischemic bowel with peritonitis requiring immediate jejunum and colon segmental resection and ileotransverse colostomy. Antibiotic treatment with Meropenem was started immediately and with Linezolid 5 hours after admission, both administered intravenously with short infusion times (15-60 min).Due to persisting excessive cytokine storm, a CytoSorbadsorber was repeatedly used (4 times over 96 hours). Therapy of septic shock including surgery, antibiotic treatment and CytoSorbresulted in a substantialimprovementof the patient’s condition including improvement in renal and liver function and cardiorespiratory status.However, after 4 weeks and seven further repeat laparotomies, the patient died from multiple organfailure.
TheuseofCytoSorbinthis patient proved to be effective (decayofIL-6 from 563.000pg/ml on day 1 to 19.400 pg/ml on day 4) andsafe(levels of meopenem and linezolid wellabove thelowertherapeutic range). Of note, intra-patient variability of antibiotic levels was high with substantially lower peak levels for both antibiotics when CytoSorb was in use, pointing towards a potential adsorption, however also due to the effects of the critical illness itself. This is the first time anin vivo pharmacokinetic monitoring of Linezolid and MeropenemduringtreatmentwithCytoSorbis described. Applyingthis regimen of dosing for Linezolid and Meropenem no negative impact on the effectiveness of antibiotic therapy was detected.
The authors suggest therapeutic drug monitoring wherever possible and if not available, high loading doses or shorter intervals of administration should be used to achieve adequate antibiotic levels. However, further studies are needed to determine the effect of CytoSorb on antibiotic levels.

Case report of 1 Patient with multiorgan failure due to severe SIRS in cardiac failure treated additional with Cytosorbents haemadsorption as adjunctive therapy

Kogelmann K, Drüner M, Jarczak D
Infection. 2015 Aug;43Suppl 1:1-73. Abstract No. 126

This case study reports on a patient with severe SIRS and multiple organ failure in...

This case study reports on a patient with severe SIRS and multiple organ failure in cardiogenic shock due to refractory cardiac arrhythmia, diffuse hypokinesia and an ejection fraction of~45 % with a heart rate of 36 bpm. After 24 hours of conventional treatment, CytoSorb therapy and CRRT was initiated due to high and stable catecholamine support associated with a persistent renal failure.During CytoSorb therapy the authors found a decrease in catecholamine demand of more than 95 % and 72 h after therapy the patient had been free of catecholamines.SOFA Score did not change while SAPS II-Score decreased to 50% of its initial value. Blood lactate, creatinine and liver enzymes decreased markedly and normalised after 2 weeks. Treatment using CytoSorb adsorption in this patient had shown great effect, been safe and without any noticed side effects. The authors note that CytoSorb therapy was helpful even in a patient with severe cardiac failure and thereby initiated severe SIRS.

Case series of patients with severe sepsis and septic shock treated with a new extracorporeal sorbent

Laddomada T, Doronzio A, Balicco B
Critical Care 2016, 20(Suppl 2):P193

In this case series in 8 patientswith severe sepsis and septic shocktreated with CytoSorbthe authors...

In this case series in 8 patientswith severe sepsis and septic shocktreated with CytoSorbthe authors analyzedthe influence of CytoSorb on clinical outcomes such as mean arterial pressure (MAP), vasopressors need and inflammatory markers, like procalcitonin (PCT). There was an overall improvement of MAP with a rapid reduction in vasopressors dosages. Moreover, CytoSorb treatment in combination with CRRT was associated with a marked decrease of PCT levels and an improvement in renal function. In non-survivors, MAP was hard to stabilize and decreased and there was an aggravation in overall patients’ conditions. The authors conclude that a timely use of CytoSorb in combination with the standard therapy could have benefits in improving patients hemodynamic and helping a more rapid stabilization. However, more in vivo studies are needed to confirm these results.

Case study of 8 Patients with multiple organ failure treated additionally with Cytosorbentshaemadsorption as adjunctive therapy in septic shock and severe SIRS in cardiac failure

Kogelmann K, Drüner M, Jarczak D
Infection. 2015 Aug;43Suppl 1:1-73. Abstract No. 58

In this case series the authorsaimed to investigate the effectiveness of CytoSorb treatment in 8...

In this case series the authorsaimed to investigate the effectiveness of CytoSorb treatment in 8 patients with sepsis/SIRS and multiple organ failure. They found a pronounced decrease in catecholamine demand and distinct tendency in decrease of blood lactatelevelsduring the treatment period and within 72 h afterCytoSorbtherapy. However, no significant changes for SOFA-Scorenor SAPS II-Score were detected. Importantly, compared with overall survival of about 45 % in severesepsis including septic shock the authors could finda survival of 62.5 % in these patients. Treatment with CytoSorb was safe and without any noticed side effects.

Clinical experience of using a novel extracorporeal cytokine adsorption column for treatment of septic shock with multiorgan failure

Sathe P, Sakhavalkar P, Kumar S, Choudhary S
Critical Care 2015, 19(Suppl 1): P130

In this retrospective case series in 19 ICU patients treated with standard of care plus...

In this retrospective case series in 19 ICU patients treated with standard of care plus CytoSorbas adjuvant therapy the authors intended to analyze clinical safety, selection of a subgroup of patients where CytoSorb could be used, selection of timing for initiation, number of CytoSorb devices required per patient, and selective markers to identify its initiation. All of the patients had a high predicted mortality(APACHE II >17, SOFA >11). Four patients could be saved with use of CytoSorb therapy. Importantly, three of them were treatedearly (<24 hours of admission). APACHE scores decreased >5 points in five patients after single application of CytoSorb therapy. Of those patients who died, the majority (n = 11) could be given CytoSorb treatment only onceand seven were treated late (>24 hours).
The authors state that a better outcome could be expected if therapy was initiated earlier (<24 hours). However, future well-designed studies are needed to clarify the role of CytoSorb in patients with MOF/septic shock.

Combination of ECMO and cytokine adsorption therapy for severe sepsis with cardiogenic shock and ARDS due to Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia and H1N1

Lees NJ, Rosenberg A, Hurtado-Doce AI, Jones J, Marczin N, Zeriouh M, Weymann A, Sabashnikov A, Simon AR, Popov AF
J Artif Organs 2016 epub

Sepsis-induced cardiogenic shock in combination with severe acute respiratory failure represents a life-threatening combination that...

Sepsis-induced cardiogenic shock in combination with severe acute respiratory failure represents a life-threatening combination that is often refractory to the conventional methods of treatment. Here the authors describe the case of a 33-year-old patient who developed acute cardiovascular collapse and ARDS secondary to superinfection of Panton-Valentine leukocidin-positive Staphylococcus aureus and H1N1 pneumonia who underwent successful combination therapy for severe sepsis-related cardiomyopathy and respiratory failure using extracorporeal membrane oxygenation and Cytosorb therapy. Use of the Cytosorb appeared to resut in rapid resolution of neutropenia, reversal of toxic shock and rapid weaning off of the high dose vasopressor infusions.

Cytokine Reduction in the Setting of an ARDS-Associated Inflammatory Response with Multiple Organ Failure

Traeger K, Schuetz C, Fischer G, Schroeder J,Skrabal C, Liebold A, Reinelt H
Case Reports in Critical Care, Volume 2016 (2016)

This case study reports on a 45-year-old male who was admitted to the hospital with...

This case study reports on a 45-year-old male who was admitted to the hospital with a small bowel obstruction due to torsion and immediately scheduled for surgical intervention. At anesthesia induction, the patient aspirated and subsequently developed a severe SIRS with ARDS and multiple organ failure requiring the use of ECMO, CRRT, antibiotics, and low dose steroids. Due to a rapid deterioration in clinical status and a concurrent surge in inflammatory biomarkers, CytoSorb was added to the CRRT blood circuit. The combined treatment resulted in a rapid and significant reduction in the levels of circulating inflammatory mediators. This decrease was paralleled by marked clinical stabilization of the patient including a significant improvement in hemodynamic stability and a reduced need for norepinephrine and improved respiratory function and indirect measures of capillary leak syndrome. The patient could be discharged to a respiratory weaning unit where successful respiratory weaning could be achieved later on. The authors attribute the clinical improvement to the rapid control of the hyperinflammatory response and the reduction of inflammatory mediators using a combination of CytoSorb and these other therapies. CytoSorb treatment was safe and well tolerated, with no device-related adverse effects observed.

CytoSorb-friend or foe!!

Pattnaik SK, Panda B.
Indian J Crit Care Med. 2015 May;19(5):296.

In this letter to the editor the authors refer to the case report by Basu...

In this letter to the editor the authors refer to the case report by Basu et al. (PMID 25538418), share their experiences with a similar patient treated with CytoSorband discuss some of the intriguing points of that treatment.A 79-year-old male patient with severe septic shock (urosepsis) and multi-organ failure and anAPACHE II score of 32, was started on CytoSorb therapy plus sustained low effusion dialysis along with standard surviving sepsis guidelines treatment. Within 3 days, hemodynamic parameters, ventilator requirements and urine output improved. APACHE II score improved from 32 before to 8 after day 3 of therapy, while IL-6 levels were reduced from 1356.3 pg/ml before to 26.12 pg/ml after the last session. Since the patient started to deteriorate clinically on the 5th day onwards despite on-going supportive care, the authors bring up a possible immunosuppressive effect and express their concern whetherCytoSorb therapy could be involved. They feel that randomized controlled trials are necessary to check the risk-benefit ratio of hemadsorption therapy in severe septic patients.

CytoSorb, a novel therapeutic approach for patients with septic shock: a case report

Hinz B, Jauch O, Noky T, Friesecke S, Abel P, Kaiser R
Int J ArtifOrgans. 2015 Sep 18;38(8):461-4

This case study reports on 72-year-old male patientwith periodically recurring infectious episodes who was admitted...

This case study reports on 72-year-old male patientwith periodically recurring infectious episodes who was admitted with the suspicionof urosepsis. In the following hours his hemodynamic situation deteriorated markedly, exhibiting respiratory-metabolic acidosis, elevated inflammatory marker plasma levels, a  severely disturbed coagulation,increasedretention parameters, liver dysfunction, and confirmation of bacteria and leucocytes in urine. After admissionto the ICU in a state of septic shock the patient received renal support with additional hemoadsorption using CytoSorb. Three CytoSorb sessions were run during the following days.The first and consecutive second session resulted in a reduction of procalcitonin, C-reactive protein and bilirubin and a markedly reduced need for vasopressors while hemodynamics improved significantly (i.e., cardiac index, extravascular lung water). Due to a recurring inflammatory “second hit” episode, another session with CytoSorb was run, resulting in a marked decrease in leukocytosis and liver (dys)function parameters. The rapid hemodynamic stabilization with reduction of vasopressor needs within hours and reduction of the capillary leakage as well as a quick reduction in infection markers were the main conclusions drawn from the use of CytoSorb in this patient. Additionally, treatment appeared to be safe and was well tolerated. Despite the promising results of CytoSorb application in his patient, further studies are necessary to elucidate to what extent these favorable consequences are attributable to the adsorber itself.

Early report: Theuse of Cytosorbhaemabsorption column as an adjunct in managing severe sepsis: initial experiences, review and recommendations

Morris C, Gray L, Giovannelli M
Journal of Intensive Care Society 0(0)

In this article the authors describe the use of CytoSorbhemoadsorption device in 2 cases of...

In this article the authors describe the use of CytoSorbhemoadsorption device in 2 cases of patients with overwhelming sepsis following community acquired pneumonia. In addition, the authors consider the experience and hitherto evidence supporting the use of CytoSorb in clinical practice. They state that while Cytosorbhaemabsorption is mechanistically distinct from other extracorporeal therapies in sepsis and appears effective in reducing inflammatory cytokines during sepsis, much of the basic science and clinical benefits remain unclear. Suggestions for future research and how Cytosorbcould be incorporated into practice are provided.

Effects of a novel cytokine haemoadsorbtion system oninflammatory response in septic shock after cephalicpancreatectomy – a case report

Tomescu D, Dima SO, Tănăsescu S, Tănase CP, NăstaseA ,Popescu M
Romanian Journal of Anaesthesia and Intensive Care2014;21(2):134-138

This case study reports on a 50 year old man with postoperative septic shockafter undergoing...

This case study reports on a 50 year old man with postoperative septic shockafter undergoing cephalic pancreatectomy for a pancreatic cystic tumor. In total,two consecutive CVVH sessions withCytoSorb were performed over a period of 64 hours(24 hours each).The clinical effects associated with CytoSorbcorrelated with a rebalance in cytokine levels and translated into a more stablehaemodynamicprofile with a stable cardiac output and normalization of systemic vascular resistance indexand decreased vasopressor requirements.Thetechnology was simple to use and could be easily added onconventional CVVH machines.The therapy was welltolerated with no adverse effects.The timing of Cytosorb whether early (after onsetof SIRS) or late (after onset of organ dysfunction) useof this novel therapy, has still to be established.

First case of toxic shock treated with haemoadsorption by CytoSorb in the Netherlands

van der Linde GW, Grootendorst A
Neth J Crit Care. 24(2): 27-29

This case study reports on a 17-year-old male who reported to the pediatrician at a...

This case study reports on a 17-year-old male who reported to the pediatrician at a local rural hospital with complaints of pretibial pain in his right leg, after he accidentally cut his leg while in the fields a few days earlier. He was diagnosedfor having aphlegmon with an abscess followed by surgical debridement with wound nettoyage with no clinical signs of subcutaneous emphysema or necrotising fasciitis. Postoperatively the patient’s condition deteriorated and after admission to ICU he developed erythema, spreading from the right lower leg to the right upper leg, abdominal wall and the left leg, consistent with toxic shock syndrome and subsequent development of septic shock due to invasive S. aureus infection with respiratory failure, hemodynamic instability treated with vasopressors, hydrocortisone, antibiotic therapy. Due disease severity, CRRT was initiated with a CytoSorbadsorber with the only goal to remove cytokines (despite absence of acute kidney injury and no need for renal replacement therapy). Within six hours after the start, the erythema progression stopped and after 12 hours the need for vasopressors diminished. The erythema diminished after a few hours and had disappeared after 24 hours. After cessation of CytoSorb physicians concluded that the patient was no longer septic and diuretics were started because of fluid overload. Respiration improved, the ventilator support was diminished and the patient was extubated on day 5 after admission, within 72 hours of cessation of CRRT. In the authors opinion, the patient would have survived without the CytoSorb, but they feel that his stay in our ICU might have been shortened by the CytoSorb adsorber

First report of cytokine removal using CytoSorb® in severe noninfectious inflammatory syndrome after liver transplantation

Tomescu DR, Dima SO, Ungureanu D, Popescu M, Tulbure D, Popescu I
Int J Artif Organs 2016

In this report the authors present the case of a 46-year-old man with primary graft...

In this report the authors present the case of a 46-year-old man with primary graft nonfunction after liver transplantation who underwent emergency retransplantation with an ABO-incompatible graft. A severe inflammatory response syndrome (SIRS) was noted in the perioperioperative period of retransplantation. The patient was successfully treated for this condition with CytoSorb in combination with CVVH throughout the intraoperative and early postoperative period.
During and after each treatment a significant and rapid decrease of pro- and anti-inflammatory cytokines was observed (IL-6, IL-10, MCP-1). Reduction of cytokines was associated with normalization of cardiac output, systemic vascular resistance, and improved liver function.
The authors believe this is the first case in which hemoadsorptionin combination with CVVH has been used to manage SIRS in a patient with primary graft nonfunction undergoing emergency retransplantation.

First successful combination of ECMO with cytokine removal therapy in cardiogenic septic shock: A case report

Bruenger F, Kizner L, Weile J, Morshuis M, Gummert JF
Int J Artif Organs. 2015 Mar 6;38(2):113-6

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS...

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS and cardiogenic septic shock. After implantation of a veno-arterial ECMO for circulatory support the patient developed acute renal failure making initiation of CVVH necessary.Due to a complete cardiac arrest in both ventricles, a left ventricular assist device (LVAD) in combination with right ECMO (rECMO) was implanted despite manifest septic conditions. In the post-operative course his condition detoriorated drastically and aCytoSorbhemoadsorption device was therefore installed in the CVVH circuit resulting in a decrease of IL-6, procalcitonin, and C-reactive protein concomitant with significantly reduced vasopressor support. No adverse device-related side effects were documented during or after the treatment sessions.This is the first clinical case report of a highly septic patient treated with the combined use of LVAD, rECMO, CVVH, and CytoSorb. The combination was practical, technically feasible, and beneficial for the patient and might represent a reasonable approach to improve survival in patients with multiple organ dysfunction necessitating several organ supportive techniques.

Hemoadsorption in Infection-Associated Rhabdomyolysis.

Suefke S, Sayk F, Nitschke M
TherApher Dial. 2016 Mar 17

This case study reports on a 55-year-old patient with history of arterial hypertension who was...

This case study reports on a 55-year-old patient with history of arterial hypertension who was admitted with complaints of dyspnea and symptoms of respiratory infection. In the further course the patient developed fulminant manifest pneumogenic sepsis and acute respiratory distress syndrome (ARDS) with massive requirements for fluids and catecholamines for hemodynamic stabilization. Plasma concentrations of myoglobin and creatine kinase increased drastically on top of his inflammatory response, indicative of massive infection-associated rhabdomyolysis. For treatment of his acute kidney injury grade III (crush kidney) and to lower inflammatory mediator and myoglobin levelsCytoSorb was installed in combination with renal replacement therapy. During the course of the treatment, plasma concentrations of IL-6, procalcitonin, myoglobin and creatine kinase decreased significantly. Levels of leucocytes, thrombocytes, alanine aminotransferase, and aspartate aminotransferase normalized over the 4 consecutive treatments. The clinical situation improved considerably including improvement of the patient’s respiratory situation and liver function. The patient was discharged at day 13 with ongoing renal failure and need for renal replacement therapy. In this patient, the application of CytoSorb resulted in a significant reduction of cytokines (i.e. IL-6) but also had an important additive effect on myglobin removal.

Hemoadsorption using Cytosorb beads (Cytosorbents) in a cirrhotic patient with septic multiorgan failure

Gruber A, Firlinger F, Lenz K, Clodi M
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 056

In this case study a 37 year old patient with alcoholic liver cirrhosis and occurring...

In this case study a 37 year old patient with alcoholic liver cirrhosis and occurring septic shock with multiorgan failure due to bilateral pneumonia (staphylococcus aureus) was successfully treated with CytoSorb. The authors found an immediate change inorgan function with stabilization of hemodynamics, as well as pulmonary andrenal function.

Improvement of hemodynamic and inflammatory parameters by combined hemoadsorption and hemodiafiltration in septic shock: a case report.

Mitzner SR, Gloger M, Henschel J, Koball S
Blood Purif. 2013;35(4):314-5.

This case study reports on an 80 year old male diagnosed of having pneumogenic septic...

This case study reports on an 80 year old male diagnosed of having pneumogenic septic shock. The patient was in clinical need for renal replacement therapy and was therefore started on citrate-anticoagulated CVVHD in combination with a CytoSorbadsorberfor 24 hours.
In the further course, plasmatic IL-6 and other markers of inflammation as well as need for vasopressors could be reduced drastically while treatment was safe and well tolerated.

Intermittent use of cytokine adsorption in combination with CRRT in a patient with necrotising pancreatitis, septic shock and MOF

Emmerich M, Zietlow S, Tiesmeier J
Infection. 2015 Aug;43Suppl 1:1-73. Abstract No. 72

This case study reports on a 60-year-old female patient with septic shock andMOF after cholecystectomy...

This case study reports on a 60-year-old female patient with septic shock andMOF after cholecystectomy which was complicatedbymassive aspiration during emergency gastroscopy and necrotizing pancreatitisrequiring necrostomy. On admission to ITU, the patient was in respiratory and acute renal failure and exhibited high needs for vasopressors and fluids. Following initial stabilization, colonic perforation and renewed septic shock occurred on day 13 post-operation,necessitating colectomy and further necrostomy on day 14.Lung-protectiveventilation and hemodynamic stabilization, antibiotic therapy and CRRT were started in the further course with a first application of Cytosorbfor 48 honday 2 post-operation anda second session for 96 h from day 13 post-operation. During thefirst 48 h of hemoadsorption, norepinephrinerequirements decreased from 0.13 to 0.00 mcg/kg/min. During thesecond use of CytoSorb the initial norepinephrine need was0.13 mcg/kg/min and rose to a maximum of 0.43 mcg/kg/min twelve hours post-operatively, however infusion could be stopped later after 40 h. Thegeneral condition of the patient improved dramatically despite further multiple operations for intra-abdominal bleeds, necrosis andwound healing impairment. CRRT could be stopped 11 days after thesecond CytoSorb treatment andtwo days later the patientwas successfully weaned from ventilation. The authors conclude that they could successfully use intermittent cytokine hemoadsorption to manage a patient with recurrent septic shock, necrotizing pancreatitis and MOF. Supplementing the standard treatment forsepsis with two applicationsof hemoadsorption facilitated rapid hemodynamic stabilization. Cytosorb was easy to use and noadverse effects were observed.

Observations in early vs. late use of CytoSorb® haemadsorption therapy in critically ill patients

Kogelmann K, Druener M, Jarczak D
Critical Care 2016, 20(Suppl 2):P195

Aim of this case study conducted in 14 critically ill patients was to show the...

Aim of this case study conducted in 14 critically ill patients was to show the effectiveness of CytoSorb treatment used as adjunctive therapy. Increased survival occured if treatment with the hemadsorption filter was started early(<48 h after diagnosis of septic shock)and patients who had a greater delay in start of therapy (>48 h after diagnosis of septic shock)had poor outcome. Start of CytoSorb therapy in nonsurvivors was by far later than in survivors. After CytoSorb therapy a pronounced decrease of catecholamine demand (Norepinephrine μg/h vs. thereby achieved MAP) was observed with catecholamine demand decreasing 10-fold. Blood lactate level was divided into halves.These observations implicate that a preferably early start of therapy not later than 24 hours after diagnosis of septic shock / severe SIRS is crucial for survival.

Pattern of cytokine removal using an adsorption columnCytoSorbduring severe Candida albicans induced septic shock

Bracht H, Schneider EM, Weiß M, Hohmann H, Georgieff M, Barth E
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 133

This case study reports on a 46 old female with hypo dynamic septic shock and documented...

This case study reports on a 46 old female with hypo dynamic septic shock and documented candidemiainfection. CRRT was started in combination with CytoSorb therapy. Within 24 h of hemoadsorption, vasopressor and inotropic support could be withdrawn. Several inflammatory mediators (e.g. IL-6, 8, 10) could be reduced significantly. Interestingly, the authors also found an almost perfect immunologicalreconstitution of a variety of immune parameters including HLA-DR.

Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy.

Hetz H, Berger R, Recknagel P, Steltzer H.
Int J Artif Organs. 2014 May;37(5):422-6

This case study reports on a 60-year-old female who was admitted to hospital due to...

This case study reports on a 60-year-old female who was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection progressing to necrotizing fasciitis with additional proven infection from β-hemolytic streptococcus. The patient went into septic shock exhibiting a full picture of a MODS. Therefore, the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 and an overall improvement of the patient’s condition. In this case, CytoSorbseems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.

Treatment of post-cardiopulmonary bypass SIRS by hemoadsorption: a case series

Traeger K, Fritzler D, Fischer G, Schröder J, Skrabal C, Liebold A, Reinelt H
Int J Artif Organs 2016; 00(00): 000-000

Objective of thiscase series in 16 adult patients undergoing standard or emergency cardiothoracic surgery procedures...

Objective of thiscase series in 16 adult patients undergoing standard or emergency cardiothoracic surgery procedures with prolonged CPB time, developing post-CPB SIRS over the course of the first post-operative 24 hours was to test the effect of CytoSorb on changes of inflammatory cytokines levels, metabolic parameters hemodynamic variables, and patient outcome. Treatment of these patients with CytoSorb in conjunction with CVVHD was associated with decreases in the proinflammatory cytokines, IL-6 and IL-8, as well as a clear stabilization of hemodynamic, metabolic and organ function parameters. All patients with an APACHE score of up to 30 survived. This is the first case series reporting the use of CytoSorb therapy in patients with post-CPB SIRS. Due to a modulation of the cytokine response, CytoSorb may offer a potentially promising new treatment option for severe post-CPB SIRS that presents with hemodynamic instability and requires high doses of vasopressors.

Use of a novel hemoadsorption device for cytokine removal as adjuvant therapy in a patient with septic shock with multi-organ dysfunction: A case study

Basu R, Pathak S, Goyal J, Chaudhry R, GoelRB, BarwalA
Indian J Crit Care Med 2014;18:822-4

This case study reports on a 36-year-old female diagnosed to have septic  (urosepsis) with multi-organ...

This case study reports on a 36-year-old female diagnosed to have septic  (urosepsis) with multi-organ dysfunction (ARDS, AKI, arterial hypotension) and a low perfusion state.SOFA score was 15, MODS score 10 and APACHE II score 30. CytoSorb was added along with CRRT. The patient received three consecutive treatments with CytoSorb in the following three days. After initiation of therapy the patient improved hemodynamically. During the further course urine output increased with improvement in ventilator parameters. SOFA score at the end of treatment was 4, MODS score was 5 and APACHE II score was 7. There were no adverse events and laboratory parameters before and after CytoSorb therapy were within normal range. CytoSorb therapy in septic shock patients with multi-organ failure might be an option as rescue therapy.

Can cytokine adsorber treatment affect antibiotic concentrations? A case report

Zoller M, Doebbeler G, Maier B, Vogeser M, Frey L, Zander J
J Antimicrob Chemother 2015; Mar 18 [Epub ahead of print]

This case study reports on a patient with an excessive inflammatory response, septic shock and...

This case study reports on a patient with an excessive inflammatory response, septic shock and MOF who was admitted to the ICU. Initial laparotomy revealed an ischemic bowel with peritonitis requiring immediate jejunum and colon segmental resection and ileotransverse colostomy. Antibiotic treatment with Meropenem was started immediately and with Linezolid 5 hours after admission, both administered intravenously with short infusion times (15-60 min). Due to persisting excessive cytokine storm, a CytoSorb adsorber was repeatedly used (4 times over 96 hours). Therapy of septic shock including surgery, antibiotic treatment and CytoSorb resulted in a substantial improvement of the patient’s condition including improvement in renal and liver function and cardiorespiratory status. However, after 4 weeks and seven further repeat laparotomies, the patient died from multiple organ failure.

The use of CytoSorb in this patient proved to be effective (decay of IL-6 from 563.000pg/ml on day 1 to 19.400 pg/ml on day 4) and safe (levels of meopenem and linezolid well above the lower therapeutic range). Of note, intra-patient variability of antibiotic levels was high with substantially lower peak levels for both antibiotics when CytoSorb was in use, pointing towards a potential adsorption, however also due to the effects of the critical illness itself. This is the first time an in vivo pharmacokinetic monitoring of Linezolid and Meropenem during treatment with CytoSorb is described. Applying this regimen of dosing for Linezolid and Meropenem no negative impact on the effectiveness of antibiotic therapy was detected.

The authors suggest therapeutic drug monitoring wherever possible and if not available, high loading doses or shorter intervals of administration should be used to achieve adequate antibiotic levels. However, further studies are needed to determine the effect of CytoSorb on antibiotic levels.

Systemic Inflammatory Response Syndrome in der Herzchirurgie: Neue Therapiemöglichkeiten durch den Einsatz eines Cytokin-Adsorbers während EKZ?

Born F, Pichlmaier M, Peter S, Khaladj N, Hagl C
Kardiotechnik 2/2014

In this retrospective observational study in 40 patients undergoing a major cardiosurgical procedure with the...

In this retrospective observational study in 40 patients undergoing a major cardiosurgical procedure with the application of a Cardio-Pulmonary-Bypass (CPB) (n=20 withCPB, n=20 with CPBand additionally implemented CytoSorb- adsorber into the circulation) the hypothesis was tested, whether the intraoperative treatment with CytoSorb has a positive effect on the developing post-operative SIRS. Results show, that CytoSorb contributes to a significant reduction of post-operative SIRS in those patients. This study further emphasizes the reliability and safety of CytoSorb also in the settingof cardio surgery.

Cytosorb™ in a patient with legionella-pneumonia associated rhabdomyolysis

Wiegele M, Krenn CG.
ASAIO J. 2015 Jan 29

This case study reports on a 44-year-old man presenting with ongoing fever and impaired general...

This case study reports on a 44-year-old man presenting with ongoing fever and impaired general condition for more than 5 days. Respiratory insufficiency finally led to hospitalization and rapid admission to an ICU with intubation and ventilatory support. Chest x-ray and computed tomography confirmed the clinical diagnosis of ARDS. Investigation of patient’s specimen further revealed infection with Legionella pneumophila. Despite administration of antibiotics, liver enzymes and parameters of renal function deteriorated in parallel within the following days, indicating a trend toward multiple organ failure. Creatine kinase and myoglobin sera levels increased in combination with reduced urine excretion. Therefore Cytosorb™ treatment was started in stand-alone mode on day 6 after admission. Within 8 hours, myoglobin levels decreased from 18,390 to 10,020 ng/ml and in a second cycle again declined from 13,400 to 8,359 ng/ml. The patient’s condition improved subsequently. Renal function completely recovered and hemo-dialysis was not necessary at any time of hospitalization. No side effects of therapy have been observed. This is the first time that a decrease of myoglo-bin levels following application of Cytosorb™ could be demonstrated in vivo.

First successful combination of ECMO with cytokine removal therapy in cardiogenic septic shock: A case report

Bruenger F, Kizner L, Weile J, Morshuis M, Gummert JF
Int J Artif Organs. 2015 Feb 3;0(0):0

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS...

This case study reports on a 39-year-old patient presenting at a hospital with fulminant ARDS and cardiogenic septic shock. After implantation of a veno-arterial ECMO for circulatory support the patient developed acute renal failure making initiation of CVVH necessary. Due to a complete cardiac arrest in both ventricles, a left ventricular assist device (LVAD) in combination with right ECMO (rECMO) was implanted despite manifest septic conditions. In the post-operative course his condition detoriorated drastically and a CytoSorb hemoadsorption device was therefore installed in the CVVH circuit resulting in a decrease of  IL-6, procalcitonin, and C-reactive protein concomitant with significantly reduced vasopressor support. No adverse device-related side effects were documented during or after the treatment sessions. This is the first clinical case report of a highly septic patient treated with the combined use of LVAD, rECMO, CVVH, and CytoSorb. The combination was practical, technically feasible, and beneficial for the patient and might represent a reasonable approach to improve survival in patients with multiple organ dysfunction necessitating several organ supportive techniques.

First description of SPAD combined with cytokine adsorption in fulminant liver failure and hemophagocytic syndrome due to generalized HSV-1 infection.

Frimmel S, Schipper J, Henschel J, Yu TT, Mitzner SR, Koball S.
Liver Transpl. 2014 Dec;20(12):1523-4

This case study reports on a 50-year-old immunocompetent woman who was admitted to hospital for...

This case study reports on a 50-year-old immunocompetent woman who was admitted to hospital for acute hepatitis with acute liver failure. After transfer to ICU the patient rapidly developed MOF and was listed for highly urgent liver transplantation. Since existing liver support techniques (MARS treatment) for bridging while awaiting for liver transplantation had no effect, SPAD in combination with CytoSorb was applied resulting in a marked decrease of IL-6, bilirubin as well as a reduction of vasopressor need. Orthotopic liver transplantation could be successfully performed on the 4th day on ICU. CytoSorb treatment was safe and well-tolerated, without any adverse events occurring. Therefore, CytoSorb seems to be promising and new approach for patients with liver failure.

Use of a novel hemoadsorption device for cytokine removal as adjuvant therapy in a patient with septic shock with multi-organ dysfunction: A case study

Basu R, Pathak S, Goyal J, Chaudhry R, Goel RB, Barwal A
Indian J Crit Care Med 2014;18:822-4

This case study reports on a 36-year-old female diagnosed to have septic shock (urosepsis) with...

This case study reports on a 36-year-old female diagnosed to have septic shock (urosepsis) with multi-organ dysfunction (ARDS, AKI, arterial hypotension) and a low perfusion state. SOFA score was 15, MODS score 10 and APACHE II score 30. CytoSorb was added along with CRRT. The patient received three consecutive treatments with CytoSorb in the following three days. After initiation of therapy the patient improved hemodynamically. During the further course urine output increased with improvement in ventilator parameters. SOFA score at the end of treatment was 4, MODS score was 5 and APACHE II score was 7. There were no adverse events and laboratory parameters before and after CytoSorb therapy were within normal range. CytoSorb therapy in septic shock patients with multi-organ failure might be an option as rescue therapy.

Effects of a novel cytokine haemoadsorbtion system on inflammatory response in septic shock after cephalic pancreatectomy – a case report

Tomescu D, Dima SO, Tănăsescu S, Tănase CP, Năstase A , Popescu M
Romanian Journal of Anaesthesia and Intensive Care 2014;21(2):134-138

This case study reports on a 50 year old man with postoperative septic shock after...

This case study reports on a 50 year old man with postoperative septic shock after undergoing cephalic pancreatectomy for a pancreatic cystic tumor. In total, two consecutive CVVH sessions with CytoSorb were performed over a period of 64 hours (24 hours each). The clinical effects associated with CytoSorb
correlated with a rebalance in cytokine levels and translated into a more stable haemodynamic profile with a stable cardiac output and normalization of systemic vascular resistance index and decreased vasopressor requirements. The technology was simple to use and could be easily added on conventional CVVH machines. The therapy was well tolerated with no adverse effects. The timing of Cytosorb whether early (after onset of SIRS) or late (after onset of organ dysfunction) use of this novel therapy, has still to be established.

Systemic Inflammatory Response Syndrome in der Herzchirurgie: Neue Therapiemöglichkeiten durch den Einsatz eines Cytokin-Adsorbers während EKZ?

Born F, Pichlmaier M, Peterß S, Khaladj N, Hagl C
Kardiotechnik 2/2014

In this retrospective observational study in 40 patients undergoing a major cardiosurgical procedure with the...

In this retrospective observational study in 40 patients undergoing a major cardiosurgical procedure with the application of a Cardio-Pulmonary-Bypass (CPB) (n=20 with CPB, n=20 with CPB and additionally implemented CytoSorb-adsorber into the circulation) the hypothesis was tested, whether the intraoperative treatment with CytoSorb has a positive effect on the developing post-operative SIRS. Results show, that CytoSorb contributes to a significant reduction of post-operative SIRS in those patients. This study further emphasizes the reliability and safety of CytoSorb also in the setting of cardio surgery.

Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy.

Hetz H, Berger R, Recknagel P, Steltzer H.
Int J Artif Organs. 2014 Apr 17;0(0):0.

This case study reports on a 60-year-old female who was admitted to hospital due to...

This case study reports on a 60-year-old female who was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection progressing to necrotizing fasciitis with additional proven infection from β-hemolytic streptococcus. The patient went into septic shock exhibiting a full picture of a MODS. Therefore,
the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 and an overall improvement of the patient’s condition. In this case, CytoSorb seems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.

Hemoadsorption using Cytosorb beads (Cytosorbents) in a cirrhotic patient with septic multiorgan failure

Gruber A, Firlinger F, Lenz K, Clodi M
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 056

In this case study a 37 year old patient with alcoholic liver cirrhosis and occuring...

In this case study a 37 year old patient with alcoholic liver cirrhosis and occuring septic shock with multiorgan failure due to bilateral pneumonie (staphylococcus aureus) was successfully treated with CytoSorb. The authors found an immediate change in organ function with stabilization of hemodynamics, as well as pulmonary and renal function.

Pattern of cytokine removal using an adsorption column CytoSorb during severe Candida albicans induced septic shock

Bracht H, Schneider EM, Weiß M, Hohmann H, Georgieff M, Barth E
Infection (2013) 41 (Suppl 1):S1–S90; Abstract No. 133

This case study reports on a 46 old female with hypo dynamic septic shock and documented...

This case study reports on a 46 old female with hypo dynamic septic shock and documented candidemia infection. CRRT was started in combination with CytoSorb therapy. Within 24 h of hemoadsorption, vasopressor and inotropic support could be withdrawn. Several inflammatory mediators (e.g. IL-6, 8, 10) could be reduced significantly. Interestingly, the authors also found an almost perfect immunological reconstitution of a variety of immune parameters including HLA-DR.

Improvement of hemodynamic and inflammatory parameters by combined hemoadsorption and hemodiafiltration in septic shock: a case report.

Mitzner SR, Gloger M, Henschel J, Koball S
Blood Purif. 2013;35(4):314-5.

This case study reports on an 80 year old male diagnosed of having pneumogenic septic...

This case study reports on an 80 year old male diagnosed of having pneumogenic septic shock. The patient was in clinical need for renal replacement therapy and therefore started on citrate-anticoagulated CVVHD in combination with a CytoSorb adsorber for 24 hours.
In the further course, plasmatic IL-6 and other markers of inflammation as well as need for vasopressors could be reduced drastically while treatment was safe and well tolerated.