Pre-clinical Studies

Effects of Blood Purification on Serum Levels of Inflammatory Cytokines and Cardiac Function in a Rat Model of Sepsis

Lin CM, Chen CR, Wu XQ, Ren JH, Chen SZ, Luo XF, Mei XQ, Shen LY, Guo MX, Ma XD, Yang T.
Blood Purif 2017: 44(1): 40-50

This sepsis rat model study explored the effects of blood purification, using a modified CytoSorb...

This sepsis rat model study explored the effects of blood purification, using a modified CytoSorb adsorber, on serum levels of inflammatory cytokines (IL6, TNF, IL10,) and cardiac function. The rat model of sepsis was established by cecal ligation and puncture. Rats were divided into normal control (n=8), sham operation (n=32), model (n=32), sham treatment (n=32), and BP treatment groups (n=32). Cardiac function, inflammatory cytokines, myocardial enzymes, pathological score of cardiac muscle tissue, and myocardial apoptosis of rats in each group were compared. Results showed that the sepsis rats had higher serum levels of inflammatory cytokines and lower cardiac function than those in the normal control and sham operation groups. Importantly, compared with the model and sham treatment groups, the CytoSorb treated group showed improved cardiac function, decreased inflammatory cytokines and myocardial enzymes, a lower pathological score, less myocardial apoptosis and a much lower mortality. The authors conclude that blood purification using CytSorb may reduce serum levels of inflammatory cytokines and improve cardiac function of septic rats.

Cytokine filtration modulates pulmonary metabolism and edema formation during ex vivo lung perfusion

Iskender I, Cosgun T, Arni S, Trinkwitz M, Fehlings S, Yamada Y, Cesarovic N, Yu K, Frauenfelder T, Jungraithmayr W, Weder W, Inci I.
J Heart Lung Transplant 2017; pub

This study tested the safety and efficacy of cytokine adsorption during ex vivo lung perfusion...

This study tested the safety and efficacy of cytokine adsorption during ex vivo lung perfusion (EVLP) in an animal model. Pig donor lungs were preserved for 24 hours at 4oC (to induce lung injury) and then randomly divided into 2 groups, the filter and control group (n=5 each), for a 12 hour EVLP procedure. In the filter group, the perfusate ran continuously through CytoSorb via a veno-venous shunt from the reservoir, whereas perfusions were run without additional filtering in the control group. Cytokine filtration with CytoSorb significantly improved airway pressure and dynamic compliance during the perfusion period. Electrolyte imbalance, glucose consumption and lactate production were markedly worse in the control group while cytokine expression profile, tissue myeloperoxidase activity and microscopic lung injury were significantly reduced in the CytoSorb treatment group. Continuous perfusate filtration through the CytoSorb beads was found to be effective and safe during prolonged EVLP and cytokine removal decreased the development of pulmonary edema and  modulated pulmonary metabolism through the suppression of anerobic glycolysis and neutrophil activation.

Ticagrelor Removal From Human Blood

Angheloiu GO, Gugiu GB, Ruse C, Pandey R, Dasari RR, Whatling C
JACC: Basic to Translational Science 2017; 2(2): 135 – 145

The authors devised a method for ticagrelor removal (platelet aggragation inhibitor) from blood using Cytosorbent...

The authors devised a method for ticagrelor removal (platelet aggragation inhibitor) from blood using Cytosorbent hemadsorption in 2 sets of in vitro experiments. The first was a first-pass experiment using bovine serum albumin (BSA) solution pre-incubated with ticagrelor, whereas the second set, performed in a recirculating manner, used human blood mixed with ticagrelor. In the recirculation set up, Ticagrelor removal from BSA solution and human blood reached values of 90% and more already after 3 – 4 hours..  CytoSorb hemadsorption was found to robustly remove ticagrelor from both BSA solutions and human blood samples.

Polystyrene-Divinylbenzene-Based Adsorbents Reduce Endothelial Activation and Monocyte Adhesion Under Septic Conditions in a Pore Size-Dependent Manner

Eichhorn T, Rauscher S, Hammer C, Groger M, Fischer MB.
Inflammation 2016; 39(5):1737-46

Endothelial activation (endothelium – tissue that acts as a barrier between the blood stream and...

Endothelial activation (endothelium – tissue that acts as a barrier between the blood stream and the surrounding tissues) with excessive recruitment and adhesion of immune cells plays a central role in the progression of sepsis. In this study the authors studied endothelial activation induced by plasma from highly septic patients and demonstrated the ability of polystyrene-divinylbenzene-based adsorbents (CytosSorb and Amberchrom) to reduce endothelial activation in a pore size-dependent manner. Specifically, in septic patients, blood was taken on admission to ICU, 1 hr and 24 hrs later. Primary monocytes were isolated and their purity and viability determined. Venous blood was also obtained from healthy volunteers. Blood from both sets of patients (normal and septic) was then diluted and passed through the adsorbers.  Following this the blood was then passed over an endothelial layer. Results showed that treatment of stimulated whole blood with polystyrene-divinylbenzene-based cytokine adsorbents (average pore sizes 15 or 30 nm) prior to passage over the endothelial layer resulted in significantly reduced endothelial cytokine and chemokine release, plasminogen activator inhibitor-1 secretion, adhesion molecule expression, and in diminished monocyte adhesion.  Researchers found that plasma samples from sepsis patients differed substantially in their potential to induce endothelial activation and monocyte adhesion despite their almost identical interleukin-6 and tumor necrosis factor-alpha levels. In conclusion, pre-incubation of the plasma samples with a polystyrene-divinylbenzene-based adsorbent (30 nm average pore size) reduced endothelial intercellular adhesion molecule-1 expression to baseline levels, resulting in significantly diminished monocyte adhesion. Data support the potential of porous polystyrene-divinylbenzene-based, including CytoSorb, to reduce endothelial activation under septic conditions by depletion of a broad range of inflammatory mediators.

In vitro adsorption of a broad spectrum of inflammatory mediators with CytoSorb® hemoadsorbent polymer beads

Gruda M
Critical Care 2016, 20(Suppl 2):P194

This study set out to quantify the ability of the CytoSorb polymer to adsorb a...

This study set out to quantify the ability of the CytoSorb polymer to adsorb a broad selection of inflammatory pathogen-associated molecular pattern molecules (PAMPs), damage-associated molecular pattern molecules (DAMPs) and cytokines from whole blood in a single compartment, in vitro recirculation system.
Hemoperfusion of whole blood through porous polymer bead devices for five hours removed substantial quantities of a broad spectrum of DAMPS, PAMPS and cytokines (S100A8, complement C5a, procalcitonin, HMGB-1, MIP1-α, IL-6, IFN-Ɣ, TNF-α, Staph enterotoxin TSST-1 and aflatoxin B1). Levels of the inflammatory proteins were reduced by <20% during the five hour hemoperfusion through a control device.
This study demonstrates that the CytoSorbpolymer is capable of reducing a broad range of toxic DAMPS and PAMPS from blood providing a means, in addition to cytokine reduction, of reducing the uncontrolled inflammatory cascade that contributes to a maladaptive SIRS response, organ injury, multiple organ dysfunction syndrome (MODS) and death in critically ill patients. Further study to elucidate the potential clinical impact is warranted.

Removal of bilirubin with a new adsorbent system: in vitro kinetics

Faenza S, Ricci D, Mancini E, Gemelli C, Cuoghi A, Magnani S, Atti M
Critical Care 2016, 20(Suppl 2):P192

The authors performed an in vitro study on bilirubin kinetics removal to verify the adsorption...

The authors performed an in vitro study on bilirubin kinetics removal to verify the adsorption capacity of CytoSorb and the ability to remove protein-bound solutes.
The study shows the effectiveness of CytoSorbin removing bilirubin, any significant loss of albumin, the resin ability to break the albumin-bilirubin complex and to adsorb irreversibly bilirubin.Cytosorb might represent a valid and simple aid in organ dysfunctions, without need of plasma separation. In vivo studies are ongoing to confirm the in vitro results.

Leukocyte capture and modulation of cell-mediated immunity during human sepsis: an ex vivo study.

Rimmele T, Kaynar AM, McLaughlin JN, Bishop J, Fedorchak M, Chuasuwan A, Peng Z, Singbartl K, Frederick DR, Zhu L, Carter M, Federspiel WJ, Zeevi A, Kellum JA.
Crit Care. 2013 Mar 26;17(2):R59

In this ex vivo study using human whole blood the authors test the hypothesis whether...

In this ex vivo study using human whole blood the authors test the hypothesis whether leukocyte capture modulates inflammatory cytokines and immune cell function.  Specially designed miniaturized extracorporeal blood purification devices (including mini cartridges with CytoSorb beads in two different sizes) were capable of capturing not only inflammatory mediators but also activated leukocytes (primarily neutrophils and monocytes).  The effects of this therapy on inflammation and immune function were examined.

Modeling competitive cytokine adsorption dynamics within hemoadsorption beads used to treat sepsis.

Kimmel JD, Harbert EM, Parker RS, Federspiel WJ.
J Chromatogr A. 2011 Nov 4;1218(44):8013-20

In this work, the authors investigate in vitro whether competitive adsorption of serum solutes affects...

In this work, the authors investigate in vitro whether competitive adsorption of serum solutes affects cytokine removal dynamics (IL-6 as representative) within the CytoSorb® hemoadsorption beads and find that competitive adsorption effects seem negligible at physiologic cytokine concentrations (<1 ng/ml).

Characterizing accelerated capture of deoligomerized TNF within hemoadsorption beads used to treat sepsis.

Kimmel JD, Lacko CS, Delude RL, Federspiel WJ.
J Biomed Mater Res B Appl Biomater. 2011 Jul;98(1):47-53.

In this work performed in vitro the authors examine the dynamics of TNF capture within...

In this work performed in vitro the authors examine the dynamics of TNF capture within the CytoSorb beads and quantify how perturbation of TNF oligomeric structure accelerates TNF removal within the device. The authors find that dissociation of TNF into its smaller monomeric constituents significantly accelerates TNF capture rates and therefore propose strategies to promote localized TNF deoligomerization at the sorbent surface.

Selective improvement of tumor necrosis factor capture in a cytokine hemoadsorption device using immobilized anti-tumor necrosis factor.

DiLeo MV, Fisher JD, Burton BM, Federspiel WJ.
J Biomed Mater Res B Appl Biomater. 2011 Jan;96(1):127-33

In this in vitro study the authors test several approaches of anti-TNF antibody immobilization onto...

In this in vitro study the authors test several approaches of anti-TNF antibody immobilization onto CytoSorb beads to improve capture rates of tumor necrosis factor.

IL-6 adsorption dynamics in hemoadsorption beads studied using confocal laser scanning microscopy.

Kimmel JD, Gibson GA, Watkins SC, Kellum JA, Federspiel WJ
J Biomed Mater Res B Appl Biomater. 2010 Feb;92(2):390-6

In this in vitro study the authors use confocal laser scanning microscopy (CLSM) to directly...

In this in vitro study the authors use confocal laser scanning microscopy (CLSM) to directly examine adsorption dynamics of fluorescently labeled IL-6 within hemoadsorption beads.

Characterization of a Novel Sorbent Polymer for the Treatment Of Sepsis.

Isabella Elfriede Valenti
Master Thesis, 2010

Objective of this in vitro study is to characterize the CytoSorb polymer with respect to...

Objective of this in vitro study is to characterize the CytoSorb polymer with respect to its adsorption properties of cytokines in different media with increasing complexity (buffer, serum, whole blood).

Experimental validation of a theoretical model of cytokine capture using a hemoadsorption device.

DiLeo MV, Fisher JD, Federspiel WJ.
Ann Biomed Eng. 2009 Nov;37(11):2310-6

Goal of this in vitro study is to show that a mathematical model which predicts...

Goal of this in vitro study is to show that a mathematical model which predicts the time course of cytokine removal by a CytoSorb device can experimentally predict the rate of cytokine capture associated with key design and operational parameters of the device (e.g. initial cytokine concentration, perfusion rate through the device, and the size of the device and of its adsorbing beads).

A simple mathematical model of cytokine capture using a hemoadsorption device.

DiLeo MV, Kellum JA, Federspiel WJ
Ann Biomed Eng. 2009 Jan;37(1):222-9. Epub 2008 Oct 24

In this in silico study the authors present a bio-mathematical model, which can calculate adsortion/removal-dynamics...

In this in silico study the authors present a bio-mathematical model, which can calculate adsortion/removal-dynamics of different cytokines (TNF, IL-6, IL-10) in the CytoSorb cartridge. They state, that removal rate of individual cytokines only depends on a single cytokine-polymer specific parameter (Γi). The model and the theroretically calculated removal dynamics correlated well with experimental data from an in vivo-performed reference study (rats with endotoxemia).

In-Vitro Myoglobin Clearance by a Novel Sorbent System

Kuntsevich VI, Feinfeld DA, Audia PF, Young W, Capponi V,MarkellaM and Winchester JF
Artif Cells Blood SubstitImmobilBiotechnol. 2009;37(1):45-7

Rhabdomyolysis (excessive break-down of muscle tissue due to crush injury, infection, drugs etc.) can...

Rhabdomyolysis (excessive break-down of muscle tissue due to crush injury, infection, drugs etc.) can result in acute kidney injury frommyoglobinuria when the myoglobin released into the blood from damaged muscle passes through the glomerular filter and accumulates in the renal tubules.
Aim of this in vitrostudy is to investigate, whether hemoadsorption (using CytoSorb) is potentially useful to effectively reduce myoglobin levels (myoglobin dissolved in 1. normal saline and 2. in serum of three donors)

Hemoadsorption to improve organ recovery from brain-dead organ donors: a novel therapy for a novel indication?

Venkataraman R, Song M, Lynas R, Kellum JA
Blood Purif. 2004;22(1):143-9

The usefulness of hemoadsorption (using CytoSorb)in maintaining organ function (liver, kidney, heart) in brain-dead donors...

The usefulness of hemoadsorption (using CytoSorb)in maintaining organ function (liver, kidney, heart) in brain-dead donors is discussed in this study. As a ‘proof of concept’ in vitro experiment the authors tested the ability of hemoadsorption to remove S100B (released from damaged brain cells exhibiting cytokine-like properties) using two human glioblastoma cell lines.

Sorbents in acute renal failure and end-stage renal disease: middle molecule and cytokine removal.

Winchester JF, Silberzweig J, Ronco C, Kuntsevich V, Levine D, Parker T, Kellum JA, Salsberg JA, Quartararo P, Levin NW
Blood Purif. 2004;22(1):73-7

This study discusses the use of hemoadsorption in acute and chronic renal failure (both are...

This study discusses the use of hemoadsorption in acute and chronic renal failure (both are inflammatory states) to reduce cytokine- and middle molecule levels. CytoSorb is discussed in detail. In vivo data are presented that show the use of CytoSorb as well as CytoSorb + conventional high-flux dialysis in patients with chronic renal failure. Results confirm, that removal of ß2 –microglobulin, angiogenin, leptin and IL-18 is much more effective when using combined therapy (CytoSorb + conventional high-flux dialysis).
Levels of leucocytes, thrombocytes and albumin were hardly affected.

Sorbents in acute renal failure and the systemic inflammatory response syndrome.

Winchester JF, Kellum JA, Ronco C, Brady JA, Quartararo PJ, Salsberg JA, Levin NW
Blood Purif. 2003;21(1):79-84

This study discusses the use of hemoadsorption in acute renal failure and other systemic inflammatory...

This study discusses the use of hemoadsorption in acute renal failure and other systemic inflammatory states to reduce cytokine- and middle molecule levels. CytoSorb is discussed in detail in the context of in vivo experiments with septic rats (endotoxin model, cecal ligation and puncture model, „Kellum-experiments“) while the known advantages of CytoSorb are discussed (reduction of cytokine levels, improvement of hemodynamics and survival)

In vitro removal of therapeutic drugs with a novel adsorbent system.

Reiter K, Bordoni V, Dall'Olio G, Ricatti MG, Soli M, Ruperti S, Soffiati G, Galloni E, D'Intini V, Bellomo R, Ronco C
Blood Purif. 2002;20(4):380-8

Aim of this in vitro study is to investigate the potential of CytoSorb to effectively...

Aim of this in vitro study is to investigate the potential of CytoSorb to effectively eliminate therapeutically administered drugs (mainly inintensive care) of middle molecular weight from uremic blood. In addition, the authors emphasize the good biocompatibility of CytoSorb.

Evaluation of the CytoSorb hemoadsorptive column in a pig model of severe smoke and burn injury.

Linden K, Scaravilli V, Kreyer SF, Belenkiy SM, Stewart IJ, Chung KK, Cancio LC, Batchinsky AI.
Shock. 2015 Nov;44(5):487-95

In this in vivo study in a porcine model of smoke inhalation and burn injury...

In this in vivo study in a porcine model of smoke inhalation and burn injury the authors aim to investigate the feasibility, technical safety and efficacy of cytokine and myoglobin removal by early use of CytoSorb.
Female Yorkshire pigs (n = 15) were injured by wood bark smoke inhalation and a 40% total body surface area deep burn and observed for 72 hours or death. The animals were randomized to hemoadsorption treatment (n = 9) or a sham treatment (n = 6) before injury and underwent a six hour hemoadsorption or sham session on days one, two and three. Serum cytokines (IL-1b, IL-6, IL-8, IL-10, TNF-alpha) and myoglobin were measured systemically, locally in bronchoalveolar lavage fluid and also in circulating blood before and after the adsorbing column resulting in a significant removal of IL-1b, IL-6, IL-10 and myoglobin across the device mainly during the first run, while systemic cytokine or myoglobin serum concentrations did not change.
The authors conclude that further investigations are needed to optimize the efficiency of mediator clearance to impact both circulating levels and clinically relevant outcomes.

Modulation of chemokine gradients by apheresis redirects leukocyte trafficking to different compartments during sepsis, studies in a rat model.

Peng ZY, Bishop JV, Wen XY, Elder MM, Zhou F, Chuasuwan A, Carter MJ, Devlin JE, Kaynar AM, Singbartl K, Pike F, Parker RS, Clermont G, Federspiel WJ, Kellum JA.
Crit Care. 2014 Jul 3;18(4):R141

In this in vivo study in a rat model of polymicrobial abdominal sepsis, the authors...

In this in vivo study in a rat model of polymicrobial abdominal sepsis, the authors investigate whether the removal of chemokines from the plasma changes chemokine gradients and subsequently enhances leukocyte localization into the infected compartment, and away from healthy tissues. The results of the study nicely demonstrate the efficacy of CytoSorb® to target leukocyte trafficking control by influencing chemokine gradients and thereby reducing leukocyte infiltration into remote healthy organs.

Role of cytokine hemoadsorption in cardiopulmonary bypass-induced ventricular dysfunction in a porcine model.

Vocelka CR, Jones KM, Mikhova KM, Ebisu RM, Shar A, Kellum JA, Verrier ED, Rabkin DG.
J Extra Corpor Technol. 2013 Dec;45(4):220-7.

This in vivo study in a porcine model undergoing cardiopulmonary bypass investigates the role of...

This in vivo study in a porcine model undergoing cardiopulmonary bypass investigates the role of hemoadsorption using CytoSorb on left ventricular function, cytokine removal, hemodynamics and noncardiac organ functions.

Effect of cytokine hemoadsorption on brain death-induced ventricular dysfunction in a porcine model.

Mikhova KM, Don CW, Laflamme M, Kellum JA, Mulligan MS, Verrier ED, Rabkin DG
J Thorac Cardiovasc Surg. 2013 Jan;145(1):215-24

This in vivo study investigates the effect of hemoadsorption (using CytoSorb) on cytokine levels (TNF...

This in vivo study investigates the effect of hemoadsorption (using CytoSorb) on cytokine levels (TNF, IL-6), cell injury (liver, kidney) and heart function (cardiac output, ventricular function) in a brain-dead porcine model.

Hemoadsorption Reprograms Inflammation in Experimental Gram-Negative Septic Peritonitis: Insights from In Vivo and In Silico Studies.

Namas RA, Namas R, Lagoa C, Barclay D, Mi Q, Zamora R, Peng Z, Wen X, Fedorchak MV, Valenti IE, Federspiel WJ, Kellum JA, Vodovotz Y
Mol Med. 2012 Dec 20;18:1366-74

This combined in vivo/in silico study in a rat model of E.coli-induced peritonitis investigates...

This combined in vivo/in silico study in a rat model of E.coli-induced peritonitis investigates whether hemoadsorption (usingCytoSorb) is able to reduce, relocalize and reprogram sepsis-induced acute inflammation (determined by analysis of 14 different cytokines and bacterial count in peritoneal fluid).

Acute removal of common sepsis mediators does not explain the effects of extracorporeal blood purification in experimental sepsis

Peng ZY, Wang HZ, Carter MJ, Dileo MV, Bishop JV, Zhou FH, Wen XY, Rimmelé T, Singbartl K, Federspiel WJ, Clermont G, Kellum JA
Kidney Int. 2012 Feb;81(4):363-9

This in vivo study in a subacute rat model of intraabdominal sepsis (cecal ligation puncture)...

This in vivo study in a subacute rat model of intraabdominal sepsis (cecal ligation puncture) investigates the effect of hemoadsorption (using CytoSorb®) that does not exert its positive effect as a direct reduction of cytokine plasma concentrations.  Levels of cytokines in this model are low, resulting in low removal by CytoSorb® (a concentration-dependent technology).  However, 7-day survival is significantly improved in the treatment group, with a reduction in latent organ injury.  Cytokine removal (TNFα, IL-1β, IL-6 und IL-10), organ injury/dysfunction (HMGB-1, ALT, and creatinine), production of cytokines (via NFkB binding in neutrophils) and 7-day survival is analyzed.  The effect of exchange blood transfusions (between CytoSorb-treated and sham animals) on IL-6 levels and 7-day mortality is also analyzed.

Effects of hemoadsorption on cytokine removal and short-term survival in septic rats

Peng ZY Carter MJ, Vellum JA
Crit Care Med. 2008 May;36(5):1573-7

In this in vivo study in a rat model of intraabdominal sepsis (cecal ligation and...

In this in vivo study in a rat model of intraabdominal sepsis (cecal ligation and puncture) the authors explore the effect of hemoadsorption (using CytoSorb) on cytokine adsorption (TNFα, IL-1β, IL-6 and IL-10), on mean arterial pressure (MAP) and short-term survival.

Hemoadsorption removes tumor necrosis factor, interleukin-6, and interleukin-10, reduces nuclear factor-kappaB DNA binding, and improves short-term survival in lethal endotoxemia.

Kellum JA, Song M, Venkataraman R.;
Crit Care Med. 2004 Mar;32(3):801-5.

This research article demonstrates that CytoSorb® hemoadsorption can improve short-term survival in a lethal endotoxin...

This research article demonstrates that CytoSorb® hemoadsorption can improve short-term survival in a lethal endotoxin challenge model of rat sepsis.  Investigators demonstrate a reduction in key cytokines and improve survival.  In addition, they demonstrate a reduction in NF-kB activity in hepatocytes taken from CytoSorb treated animals versus sham treated animals, suggesting the ability to not just remove cytokines, but to also down-regulate cytokine production.

Cytokine removal with a novel adsorbent polymer.

Song M, Winchester J, Albright RL, Capponi VJ, Choquette MD, Kellum JA.
Blood Purif. 2004;22(5):428-34.

This study characterizes the CytoSorb adsorbent polymer in terms of cytokine removal in 50 LPS...

This study characterizes the CytoSorb adsorbent polymer in terms of cytokine removal in 50 LPS challenged rats by measuringTNF alpha, interleukin 10 and interleukin 6 concentrations under a variety of conditions to evaluate adsorption kinetics. The authors found that all three cytokines were rapidly removed from the blood with less than 50% of the initial concentrations present after 1 h of circulation through the cartridge pointing towards a high efficiency, while binding is relatively unaffected by a variety of physical conditions.