Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 77-82

Low-volume plasma exchange and low-dose steroid to treat secondary hemophagocytic lymphohistiocytosis: A potential treatment for severe COVID-19?

1 Department of Hepatology, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
2 Division of Critical Care, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Medicine - Medicine Unit I, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
4 Department of Transfusion Medicine and Immunohaematology, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
5 Department of Nephrology, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
6 Department of The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
7 Department of Research Haematology, University College London, London, United Kingdom
8 Department of Hepatology, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India; Liver Unit, University Hospitals Birmingham, Birmingham, United Kingdom

Date of Submission04-Apr-2020
Date of Decision06-Apr-2020
Date of Acceptance07-Apr-2020
Date of Web Publication09-Apr-2020

Correspondence Address:
Dr. C E Eapen
Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_48_20

Rights and Permissions

Secondary hemophagocytic lymphohistiocytosis (sHLH) may be responsible for some of the deaths in adult patients with severe COVID-19. We present our experience of low-volume plasma exchange (PLEX) with low-dose steroid in the treatment of adult patients with sHLH and acute liver failure caused by dengue virus and other nonviral triggers and discuss how this may be effective in the management of severe COVID-19. sHLH is poorly understood and without effective treatment. Endothelium of the capillaries of the lungs and kidneys and of liver sinusoids does not express von Willebrand factor (VWF) in health and is where most macrophages are located. Plasma VWF levels are high in sHLH and require clearance by macrophages, which when activated enlarge and likely block the lumen. Current histology studies neither appreciate microcirculatory sludge nor display endothelial–macrophage interactions. We hypothesize that low-volume PLEX and low-dose steroid may reverse sHLH and improve survival in severe COVID-19 patients with acute lung injury.

Keywords: Ameliorate macrophage activation, plasma exchange, steroid

How to cite this article:
Alexander V, Zachariah U, Goel A, Kandasamy S, Chacko B, Punitha JV, Nair S, David V, Prabhu S, Balasubramanian K A, Mackie I, Elias E, Eapen C E. Low-volume plasma exchange and low-dose steroid to treat secondary hemophagocytic lymphohistiocytosis: A potential treatment for severe COVID-19?. Curr Med Issues 2020;18:77-82

How to cite this URL:
Alexander V, Zachariah U, Goel A, Kandasamy S, Chacko B, Punitha JV, Nair S, David V, Prabhu S, Balasubramanian K A, Mackie I, Elias E, Eapen C E. Low-volume plasma exchange and low-dose steroid to treat secondary hemophagocytic lymphohistiocytosis: A potential treatment for severe COVID-19?. Curr Med Issues [serial online] 2020 [cited 2022 Aug 13];18:77-82. Available from: https://www.cmijournal.org/text.asp?2020/18/2/77/282180

  Secondary Hemophagocytic Lymphohistiocytosis in Severe Covid-19 patients Top

Macrophages, cells of the innate immune system, respond rapidly (within 20–30 min) once the host recognizes an invading microbe by phagocytosis. However, uncontrolled macrophage activation//secondary hemophagocytic lymphohistiocytosis (sHLH) commonly triggered by viruses can lead to cytokine storm, multi-organ failure, and death.

Among hospitalized adult COVID-19 patients, serum ferritin (a marker of macrophage activation) and interleukin-6 (a pro-inflammatory cytokine) levels were significantly higher in nonsurvivors and increased with worsening illness.[1] In view of cytokine storm[2] and sHLH, it has been suggested that severe COVID-19 patients be screened for hyperinflammation (increasing ferritin levels, decreasing platelet counts, and HScore [used to diagnose sHLH]) to consider immunosuppressive therapy.[3]

sHLH pathophysiology is poorly understood and better insight into its mechanisms, and treatment may improve survival.

  Our Hypothesis Top

Low-volume PLEX and low-dose steroid may improve survival in patients with sHLH and acute lung/liver injury by ameliorating macrophage overactivation. We postulate that this treatment may improve survival in severe COVID-19.

  Support for the Hypothesis Top

We present our experience using a low-volume PLEX and low-dose steroid protocol [Supplementary Material] to treat patients with sHLH and acute liver failure due to dengue virus and other nonviral triggers. Data from a prospectively maintained database of patients with acute liver failure treated by this protocol in our department were retrospectively analyzed for this purpose, after obtaining approval from our institutional review board and ethics committee. We discuss the link between activation of endothelium and of macrophages in sHLH. Endothelium of the capillaries of the lungs and kidneys and of the liver sinusoids does not express von Willebrand factor (VWF) in health and is where most macrophages are located. Plasma VWF levels are high in sHLH and require clearance by macrophages, which when activated enlarge and likely impede microcirculatory perfusion in these organs. The similarities between sHLH and associated organ failure in severe COVID-19 and viral (dengue)/nonviral triggers and its implications are discussed.

  Our Preliminary Experience With Low-volume Plasma Exchange and Low-dose Steroid to Treat Dengue-induced Secondary Hemophagocytic Lymphohistiocytosis and Acute Liver Failure Top

Of three patients with dengue-induced sHLH, acute liver failure, and multi-organ failure, treated with this protocol, two patients who did not require mechanical ventilation had reduction in sequential organ failure assessment (SOFA)[4] scores and hyperinflammation and survived [Table 1].
Table 1: Low-volume plasma exchange and low-dose steroid to treat dengue-induced secondary hemophagocytic lymphohistiocytosis, acute liver failure, and multi-organ failure

Click here to view

  Our Preliminary Experience With Low-volume Plasma Exchange and Low-dose Steroid in Nonviral Acute Liver Injury/failure Top

Alcohol, drugs, and toxins can also trigger macrophage overactivation, and our preliminary experience with this treatment protocol in acute liver injury/failure or acute-on chronic liver failure is promising. Of our first 100 patients, 72 were treated in the high-dependency unit and 28 in the intensive care unit; 51 had acute liver injury/failure and 38 had acute-on chronic liver failure. These 100 patients underwent a median of three (range 2–5) sessions of PLEX, and 1·5 (0·5–2) litres of plasma was exchanged per se ssion with fresh frozen plasma. Etiologies for liver disease included alcohol (24 patients), phosphorus poisoning (18), and idiosyncratic drug-induced liver injury (16).[5] Of 39 patients (acute liver injury/failure: 15, and acute-on chronic liver failure: 24 patients) tested, all had markedly raised serum sCD163 (marker of macrophage activation) levels and this correlated with disease severity and in-hospital mortality.[6]

Of 21 patients with very severe alcoholic hepatitis[7] (median model for end-stage liver disease [MELD] score of 32 [28–42] and median discriminant function score[7] of 91.8 [70.7–159.6]) treated by this protocol, 13 (62%) survived without liver transplantation.[8] Of 13 patients with idiosyncratic drug-induced liver injury who met criteria for liver transplantation treated by this protocol, six patients survived without liver transplantation.[9] Of ten patients with rodenticidal hepatotoxicity who met the listing criteria for liver transplantation (median MELD score 39 [36–40]) treated by this protocol, five patients (50%) survived without liver transplantation.[10]

Improved survival has been reported with low-volume of plasma exchanged in acute-on chronic liver failure patients with milder grade of disease severity.[11]

  The Possible Link between Activation of Endothelium and of Macrophages in Secondary Hemophagocytic Lymphohistiocytosis Top

The change in terminology from reticuloendothelial system to mononuclear phagocyte system suggests close link between endothelium and macrophages.

Raised levels of the plasma VWF (a platelet adhesive protein released from endothelium), low levels of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), an enzyme which cleaves VWF, and thrombocytopenia are recognized in viral infections such as dengue.[12] VWF-rich platelet plugs may block microcirculation in acute inflammatory syndromes – termed as secondary thrombotic microangiopathies; reduced microcirculatory perfusion of vital organs is recognized as functional organ failure by a clinician at the bedside.

Endothelial cells lining the capillaries in the lungs and renal glomeruli[13] and sinusoids in the liver[14] do not express VWF in health. These “VWF-free” zones are narrow (diameter of the lung capillaries is 6.3 μm[15] and of the liver sinusoids is 9–10 μm[16]). VWF-rich microthrombi were noted at autopsy in children with reduced ADAMTS13 levels, multi-organ failure, and thrombocytopenia.[17] In a prospective multicenter trial, PLEX led to resolution of organ dysfunction and better 28-day survival in children with multi-organ failure and thrombocytopenia.[18]

Animals (foals) dying of sepsis have increased lung inflammation, increased VWF expression in the lung capillaries, as well as increase in pulmonary intravascular macrophages and VWF positivity demonstrated on the macrophage surface.[19] VWF is removed from the circulation by macrophages and hepatocytes.[20],[21] While macrophages are present in all tissues, they are predominantly located in the liver sinusoids (called Kupffer cells) and lung capillaries.[22]

It seems important to keep these narrow low-pressure “VWF-free” traffic zones patent (i.e., avoid VWF-rich platelet microthrombi to form), to allow free flow of traffic (blood flow) through the capillaries of the lungs and kidneys and sinusoids in the liver. These same narrow traffic zones in the liver and lungs provide “parking slots” for macrophages and may contribute to lumen narrowing as macrophages get activated in sHLH.

  High Von Willebrand Factor Levels in Microcirculation: Relevance of Coiled and Stretched-out Von Willebrand Factor Forms Top

VWF molecules released from the endothelial cells travel in the blood stream mainly as coiled forms; hence, the binding sites for platelets and ADAMTS13 are less exposed.[23] When VWF tethered to subendothelial collagen (at site of a vessel wall breach) is stretched out by shear stress of flowing blood, it exposes its platelet binding site. VWF also carries factor VIII (a coagulation factor). Thus, damage to the vessel wall localizes platelets and VWF (and factor VIII).

What are the consequences of increased endothelial VWF expression and of increased VWF levels in microcirculation? In health, high molecular weight VWF multimers (5000–10,000 kDa) comprise the main form of VWF in circulation.[23] In viral sHLH, it is likely that large-coiled VWF may sludge capillaries/liver sinusoids. The stretched-out VWF due to increased shear stress in arterioles attracts more platelets, recognized by the clinician as thrombocytopenia. Microthrombi in the areas of infection may be an innate immune response to contain infection and is termed immunothrombosis.[24]

  Plasma Exchange Protocol May Ameliorate Macrophage Activation and Improve Multi-organ Dysfunction and Survival in Patients With Acute Liver Injury/failure Top

High-volume PLEX (8–12 litres of plasma exchanged with fresh frozen plasma daily for 3 days) attenuated innate immune activation, ameliorated multi-organ dysfunction, and improved liver transplant-free survival by about 10% in acute liver failure.[25] As this survival benefit is not seen with renal replacement therapy, we postulate that molecules too large (>60 kDa) to be removed by dialysis may be removed by PLEX in these patients. VWF is the largest known protein in the normal human plasma.[23] High molecular weight VWF multimers (up to 10,000 kDa) will not be removed by dialysis. Raised plasma VWF levels accurately predicted in-hospital mortality in 24 patients with acute hepatotoxicity (20 patients had acute liver injury, while three had acute liver, failure)[26] and in 50 patients with acute-on chronic liver failure.[27] Thus, VWF pheresis may explain the survival benefit of PLEX in patients with liver failure.[28] VWF reduction is being explored to treat acute liver failure syndromes.[26],[29],[30] In patients with raised plasma VWF levels, PLEX reduces plasma VWF levels by two mechanisms: by removing VWF in the pheresed plasma and by supplementing ADAMTS13 (a VWF cleaving protease) in the form of replaced fresh frozen plasma.

The three dengue-induced sHLH and acute liver failure patients in our report [Table 1] had raised plasma VWF levels (3.7–5.7-fold above upper limit of normal). As VWF is cleared by macrophages, we postulate that the increased VWF load in circulation may contribute to continued macrophage activation. We hypothesize that PLEX reduces the raised plasma VWF load, which in turn may ameliorate macrophage overactivation in sHLH patients.

  Acute Failure of Liver/lungs May Be Due to a “traffic Jam” in Its Microcirculation Top
[Figure 1]
Figure 1: The flow of traffic at 9 am (a) in front of Christian Medical College, Vellore hospital, resembles “traffic jam in the narrow lanes” in liver sinusoids/lung capillaries in secondary hemophagocytic lymphohistiocytosis while (b) normal traffic flow at 5 pm. In health, the lumen of lung capillaries and of liver sinusoids should contain 50% of blood cells and 50% of plasma; in secondary hemophagocytic lymphohistiocytosis, the lumen is drastically narrowed by hyperinflammation and leads to reduced organ perfusion and organ failure. Credits: Dr. Kirti Anna Koikkara.

Click here to view

An acute increase in the number and size of macrophages in the endothelial lining as well as arrival of innate immune cells (such as monocytes and neutrophils) and of large-sized proteins such as VWF (for clearance by macrophages) will further narrow the lumen in the narrow, low-pressure “VWF-free zones” in vital organs. What are the possible consequences of acute obstruction to flow in liver sinusoids and lung/renal capillaries? It is interesting to note that a physiological PLEX occurs through fenestrated endothelial cells lining the hepatic sinusoids in health.[31] Acute reduction in microcirculatory perfusion in a vital organ will lead to acute organ dysfunction, and when reduction in perfusion crosses a critical threshold, tissue necrosis and organ failure are likely.

Why is this “traffic jam” not well recognized on histology studies?

Antemortem tissue biopsies do not retain the free-flowing intravascular contents; hence, microcirculatory sludge in any organ is not appreciated in these biopsies. Newer techniques are needed to study this. It is possible that postmortem studies, i.e. after blood flow in circulation has ceased, may appreciate the microcirculatory sludge better. Indeed, postmortem studies in 50 acute liver failure patients demonstrated congestion of capillaries as the most common histopathological finding in lungs (in 50% of patients), in kidneys (in 58%), and in liver (in 40%). This was associated with hepatic necrosis (in 62% of patients) and acute renal tubular necrosis (in 44%).[32]

  Primary Versus Secondary Hemophagocytic Lymphohistiocytosis: Relevance to Covid-19 Top

Macrophage activation is kept in check by natural killer cells and/or cytotoxic T-lymphocytes. The latter cells may either create a hole on the macrophage surface (via perforins) or encourage macrophage death (through granules with potent cytolytic enzymes [such as granulysin] inserted into the macrophage). Absent/reduced natural killer cell/cytotoxic T-cell function leading to uncontrolled macrophage activation is termed primary HLH.[33]

In contrast to primary HLH, in sHLH, the natural killer cells/cytotoxic T-cells may get overactivated, in an attempt to control the macrophage overactivation. A patient who died of COVID-19 had high concentrations of cytotoxic granules in the peripheral blood CD8 T-cells (32% cells were perforin positive, 64% were granulysin positive, and 31% were positive for both).[34] It is possible that this T-cell overactivation reflects the natural killer/cytotoxic T-cells machinery, attempting to control the macrophage overactivation. The collateral damage by this overactive T-cell response may add to the lung injury.

  How Does Treatment of Dengue-induced Acute Liver Failure Have Relevance to Acute Lung Injury in Severe Covid-19? Top

Hyperferritinemia in severe dengue [Table 1] and severe COVID-19[1] patients and raised serum sCD 25 levels[35] and HScore >169[36] in dengue patients suggest macrophage activation syndrome/sHLH [Table 1].

Postmortem lung biopsies indicate sHLH in patients with severe acute respiratory syndrome (SARS) due to SARS-associated coronavirus[37] and avian influenza A (H5N1) infection[38] (marked increase in macrophages in alveoli and in interstitium[37] and hemophagocytosis[37],[38]). Fibrin thrombi in the pulmonary vessels were also noted in one patient.[38] Overactivated CD8 T-cells in a severe COVID-19 patient[34] suggest the expected cytotoxic T-cell response to macrophage overactivation in sHLH.

Raised VWF load in the plasma may trigger continued macrophage activation as macrophages work to clear the VWF load. Macrophage activation triggers cytokine storm. “Traffic jam” in the liver sinusoids (in dengue-induced acute liver failure) and in the lung capillaries (in COVID-19 patients) and in other vital organs will lead to reduced perfusion and failure of these organs.

  Some Points to Highlight in Our Treatment Protocol Top

  1. Outcomes are best, when treatment is implemented at the stage of acute liver injury, rather than acute liver failure
  2. We start low-dose steroid before starting PLEX and continue for 1–4 weeks after. This strategy appears to ameliorate the secondary macrophage activation syndrome/sHLH
  3. Low volume of exchanged plasma appears effective
  4. The replacement fluid is fresh frozen plasma from healthy donors[25] at 1:1 volume (so that the pheresed plasma does not render the patient immune depleted and more prone to sepsis. In addition, ADAMTS13 in the infused fresh frozen plasma has a VWF lowering effect)
  5. We avoid isolated platelet transfusion in patients with thrombocytopenia in the setting of activated endothelium (reflected by raised plasma VWF levels).[39]

  Implications and Unknowns of the Hypothesis Top

While our report of viral (dengue)-induced sHLH and acute liver failure is limited to three patients [Table 1], it provides a mechanistic explanation why lung and other multi-organ failure occur in COVID-19 patients. Our preliminary experience with dengue-induced sHLH does not prove that low-volume PLEX and low-dose steroid ameliorate macrophage overactivation and improve survival in viral sHLH. However, our experience with more number of patients with acute liver injury/failure due to other causes (who also have sHLH) treated by this protocol is encouraging.

Plasma obtained from healthy unselected donors from the blood bank was used in PLEX treatment of our three dengue patients. We did neither use convalescent plasma from individuals who recovered recently from dengue nor were dengue antibodies tested in the donor plasma.

Unlike dengue which is arthropod borne, SARS-CoV2 which causes COVID-19 is highly contagious. Hence, healthcare workers need to take appropriate personal protective measures when managing critically ill COVID-19 patients.

Due to concern that steroid may delay viral clearance, it has been suggested that steroid should not be routinely used in patients with COVID-19 and acute lung injury.[40] The risks and benefits of low-dose steroid advocated in our treatment protocol need to be tested in clinical trials of severe COVID-19 patients.

  How to Test the Hypothesis Top

Markers of activation of macrophages (such as raised serum ferritin levels and raised serum sCD163 levels) and of endothelium (such as thrombocytopenia and raised plasma VWF levels) need to be studied in COVID-19 patients across a spectrum of disease severity.

COVID-19 patients with less severe acute lung injury (organ dysfunction, before onset of organ failure) need to be selected for the treatment with low-volume PLEX and low-dose steroid. The window for this therapeutic intervention is likely to be narrow and needs to be defined in appropriately designed studies.


We gratefully acknowledge the technical inputs and support from Dr. Shibu Jacob, Nephrology Department, and Dr. Dolly Daniel and Dr. Joy Mammen, Transfusion Medicine and Immunohaematology Department, Christian Medical College Hospital, Vellore, India, for providing PLEX therapy for acutely ill patients in liver failure.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  Supplementary Material Top

Low-volume plasma exchange (PLEX) and low-dose steroid to treat acute liver injury/failure OR acute-on chronic liver failure: The Vellore Protocol


  1. Acute liver injury/failure±other vital organ injury/failure
  2. Secondary hemophagocytic lymphohistiocytosis (HLH) (serum ferritin≥500 ng/mL)[1]
  3. Endothelial activation (raised plasma von Willebrand factor [VWF] levels).


  1. Recent major bleed (gastrointestinal, intracranial, pulmonary, intravitreal, etc., in the last 2 weeks. As VWF is a blood clotting protein, we are concerned about precipitating further bleeding by VWF depletion)
  2. Ongoing sepsis
  3. Hemodynamic instability after appropriate resuscitation and vasopressor support of>0.5 mcg/kg/min of noradrenaline or a second vasoactive drug to maintain a mean arterial pressure of 65 mmHg.


  1. Patients are admitted to a monitored setting (high-dependency unit/ITU)
  2. Obtain patient/next of kin consent after counseling about all other treatment options
  3. Femoral vein is our preferred access for PLEX port insertion under ultrasound guidance.[2] This access is exclusively for PLEX and not used for any other reason (e.g. obtaining blood samples, administering medicines). We do not use prophylactic platelet transfusion for line insertion
  4. We avoid sedation (to reduce need for mechanical ventilation and risk of precipitating encephalopathy). Patients at risk of aspiration or who develop respiratory failure are intubated on a case-by-case basis
  5. We do not give prophylactic platelet transfusions. In case of need for platelet transfusion to cover for an invasive procedure, we give fresh frozen plasma infusions (to supplement ADAMTS13) before giving platelet concentrates
  6. It is preferable to avoid invasive diagnostic tests, until this treatment is completed
  7. We give empiric antibiotic after blood culture
  8. Tablet Prednisolone 10 mg or equivalent is started as soon as decision to PLEX taken and continued for at least 1 week after stopping PLEX. Longer duration (up to 4 weeks) of steroids, if needed, may be given after reassessing the patient™s overall condition
  9. Plasma volume is estimated by Kaplan method[3] [0.065 × weight (kg)] × (1 − hematocrit). We target 50% of plasma volume to be exchanged per the PLEX session. In case of major bleed (2–4 weeks ago)/treated sepsis/significant hemodynamic instability, 25% of plasma volume is exchanged
  10. The replacement fluid is fresh frozen plasma at 1:1 volume (so that the pheresed plasma does not render the patient immune depleted and more prone to sepsis. In addition, ADAMTS13 in the infused fresh frozen plasma has a VWF-lowering effect).
  11. Centrifugal-type PLEX is preferred to membrane-type PLEX
  12. PLEX is done daily and three sessions targeted; the decision on performing PLEX is to be reviewed each day; the total number of sessions of PLEX is decided based on tolerability/patient™s clinical condition. During PLEX, strict asepsis/avoid hemodynamic instability/give adequate calcium supplementation. Remove port as soon as need for PLEX is over
  13. Infection surveillance: We do daily surveillance blood culture on days of PLEX. In case of bacteremia/clinical signs of worsening sepsis while on PLEX, withhold/discontinue PLEX until sepsis is controlled.
  14. N-Acetyl cysteine[4] (as a VWF-lowering measure, oral or intravenous) and oral zinc (aimed to reduce gut permeability) are also given for 2–4 weeks
  15. Organ-specific standard of care for critically ill patient to continue.

References (for Supplementary Material–PLEX Protocol)

  1. La Rosée P, Horne A, Hines M, von Bahr Greenwood T, Machowicz R, Berliner N, et al. Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood 2019;133:2465-77.
  2. Patel L, Jacob S, Mathews N, Mammen J, Nair SC, Vijayalekshmi B, et al. Plasma exchange therapy in liver failure: Femoral port insertion may be preferable Indian J Gastroenterol 2018;37(Suppl 1):A79 Abstract # 259.
  3. Kaplan AA. A simple and accurate method for prescribing plasma exchange. ASAIO Trans 1990;36:M597-9.
  4. Chen J, Reheman A, Gushiken FC, Nolasco L, Fu X, Moake JL, et al. N-acetylcysteine reduces the size and activity of von Willebrand factor in human plasma and mice. J Clin Invest 2011;121:593-603.

  References Top

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62. Erratum in: Lancet 2020;395:1038.  Back to cited text no. 1
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 2
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 3
Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 1998;26:1793-800.  Back to cited text no. 4
Santhosh Kumar E, Varunmai NL, Sharma A, Thomas L, Subramani K, Jacob S, et al. Plasma exchange (PLEX) a novel rescue treatment modality in liver failure syndromes: Our experience with first 100 patients. J Gastroenterol Hepatol 2019;34(S3):353. PP 0558.  Back to cited text no. 5
Sharma A, Vijayalekshmi B, Prabhu SB, Nair SC, Mammen J, Jacob S, et al. Macrophage activation in liver failure. J Gastroenterol Hepatol. 2019;34(S3):262. PP 0377.  Back to cited text no. 6
Crabb DW, Bataller R, Chalasani NP, Kamath PS, Lucey M, Mathurin P, et al. Standard definitions and common data elements for clinical trials in patients with alcoholic hepatitis: recommendation from the NIAAA alcoholic hepatitis consortia. Gastroenterology 2016;150:785-90.  Back to cited text no. 7
Santhosh Kumar E, Barpha AS, Gandhi PB, Sharma A, Thomas L, Subramani K, et al. Plasma exchange - a promising treatment modality in very severe alcoholic hepatitis patients. J Gastroenterol Hepatol 2019;34(S3):330. PP 0513.  Back to cited text no. 8
Santhosh Kumar E, Jacob S, Thomas L, Subramani K, Sharma A, Goel A, et al. Plasma exchange: A potential treatment option in idiosyncratic drug induced liver failure. J Gastroenterol Hepatol 2019;34(S3):473. PP 0799.  Back to cited text no. 9
Sharma A, Kumar SE, Thomas L, Subramani K, Jacob S, Nair SC, et al. Plasma Exchange to Treat Yellow Phosphorus Induced Liver Injury. J Gastroenterol Hepatol 2019;34(S3):757. PE 0348.  Back to cited text no. 10
Deshpande A, Kumbar S, Patil S, Jayaprakash A, Menon P, Somu A, et al. Plasma exchange therapy in patients with ACLF, experience from a tertiary care centre. J Clin Exp Hepatol 2018;8 (Suppl 1):S3.  Back to cited text no. 11
Djamiatun K, van der Ven AJ, de Groot PG, Faradz SM, Hapsari D, Dolmans WM, et al. Severe dengue is associated with consumption of von Willebrand factor and its cleaving enzyme ADAMTS-13. PLoS Negl Trop Dis 2012;6:e1628.  Back to cited text no. 12
Pusztaszeri MP, Seelentag W, Bosman FT. Immunohistochemical expression of endothelial markers CD31, CD34, von Willebrand factor, and Fli-1 in normal human tissues. J Histochem Cytochem 2006;54:385-95.  Back to cited text no. 13
Baruch Y, Neubauer K, Ritzel A, Wilfling T, Lorf T, Ramadori G. von Willebrand gene expression in damaged human liver. Hepatogastroenterology 2004;51:684-8.  Back to cited text no. 14
Townsley MI. Structure and composition of pulmonary arteries, capillaries, and veins. Compr Physiol 2012;2:675-709.  Back to cited text no. 15
Warren A, Chaberek S, Ostrowski K, Cogger VC, Hilmer SN, McCuskey RS, et al. Effects of old age on vascular complexity and dispersion of the hepatic sinusoidal network. Microcirculation 2008;15:191-202.  Back to cited text no. 16
Nguyen TC, Han YY, Kiss JE, Hall MW, Hassett AC, Jaffe R, et al. Intensive plasma exchange increases a disintegrin and metalloprotease with thrombospondin motifs-13 activity and reverses organ dysfunction in children with thrombocytopenia-associated multiple organ failure. Crit Care Med 2008;36:2878-87.  Back to cited text no. 17
Fortenberry JD, Nguyen T, Grunwell JR, Aneja RK, Wheeler D, Hall M, et al. Therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure: The thrombocytopenia-associated multiple organ failure network prospective experience. Crit Care Med 2019;47:e173-e181.  Back to cited text no. 18
Harrison JM, Quanstrom LM, Robinson AR, Wobeser B, Anderson SL, Singh B. Expression of von Willebrand factor, pulmonary intravascular macrophages, and Toll-like receptors in lungs of septic foals. J Vet Sci 2017;18:17-23.  Back to cited text no. 19
Lenting PJ, Christophe OD, Denis CV. von Willebrand factor biosynthesis, secretion, and clearance: Connecting the far ends. Blood 2015;125:2019-28.  Back to cited text no. 20
Casari C, Lenting PJ, Wohner N, Christophe OD, Denis CV. Clearance of von Willebrand factor. J Thromb Haemost 2013;11 Suppl 1:202-11.  Back to cited text no. 21
Laskin DL, Weinberger B, Laskin JD. Functional heterogeneity in liver and lung macrophages. J Leukoc Biol 2001;70:163-70.  Back to cited text no. 22
Stockschlaeder M, Schneppenheim R, Budde U. Update on von Willebrand factor multimers: Focus on high-molecular-weight multimers and their role in hemostasis. Blood Coagul Fibrinolysis 2014;25:206-16.  Back to cited text no. 23
Engelmann B, Massberg S. Thrombosis as an intravascular effector of innate immunity. Nat Rev Immunol 2013;13:34-45.  Back to cited text no. 24
Larsen FS, Schmidt LE, Bernsmeier C, Rasmussen A, Isoniemi H, Patel VC, et al. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol 2016;64:69-78.  Back to cited text no. 25
Sardar D, Mathews N, Mammen J, Nair SC, Jacob S, Patel L, et al. Rodenticidal hepatotoxicity: Raised plasma von Willebrand factor levels predict in-hospital survival and preliminary report of the outcome of von Willebrand factor reducing management protocol. Indian J Gastroenterol 2019;38:527-33.  Back to cited text no. 26
Prasanna KS, Goel A, Amirtharaj GJ, Ramachandran A, Balasubramanian KA, Mackie I, et al. Plasma von Willebrand factor levels predict in-hospital survival in patients with acute-on-chronic liver failure. Indian J Gastroenterol 2016;35:432-40.  Back to cited text no. 27
Gandhi PB, Mathews N, Mammen J, Nair SC, Jacob S, Vijayalekshmi B, et al. von Willebrand factor (vWF)-pheresis: A possible explanation how plasma exchange is beneficial in liver failure. Hepatol Int 2019;13 (Suppl 1):S3 A 272.  Back to cited text no. 28
Groeneveld D, Cline-Fedewa H, Baker KS, Williams KJ, Roth RA, Mittermeier K, et al. von Willebrand factor delays liver repair after acetaminophen-induced acute liver injury in mice. J Hepatol 2020;72:146-55.  Back to cited text no. 29
Goel A, Nair SC, Zachariah U, Balasubramanian KA, Mackie I, Elias E, et al. Targetting the raised von Willebrand factor levels in liver diseases: opening up newer therapeutic avenues. European EMJ Hepatol 2020;8.[In press].  Back to cited text no. 30
Braet F, Wisse E. Structural and functional aspects of liver sinusoidal endothelial cell fenestrae: A review. Comp Hepatol 2002;1:1.  Back to cited text no. 31
Das S, Reddy UVUV, Hamide A, Badhe B, Ravichandran M, Murthy AS. Histopathological profile in fatal yellow phosphorous poisoning. J Forensic Sci 2019;64:786-90.  Back to cited text no. 32
La Rosée P, Horne A, Hines M, von Bahr Greenwood T, Machowicz R, Berliner N, et al. Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood 2019;133:2465-77.  Back to cited text no. 33
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020 Feb 18. [Epub ahead of print] Erratum in: Lancet Respir Med 2020 Feb 25.  Back to cited text no. 34
Hutchinson M, Tattersall RS, Manson JJ. Haemophagocytic lymphohisticytosis-an underrecognized hyperinflammatory syndrome. Rheumatology (Oxford) 2019;58:vi23-30.  Back to cited text no. 35
Fardet L, Galicier L, Lambotte O, Marzac C, Aumont C, Chahwan D, et al. Development and validation of the HScore, a score for the diagnosis of reactive hemophagocytic syndrome. Arthritis Rheumatol 2014;66:2613-20.  Back to cited text no. 36
Nicholls JM, Poon LL, Lee KC, Ng WF, Lai ST, Leung CY, et al. Lung pathology of fatal severe acute respiratory syndrome. Lancet 2003;361:1773-8.  Back to cited text no. 37
To KF, Chan PK, Chan KF, Lee WK, Lam WY, Wong KF, et al. Pathology of fatal human infection associated with avian influenza A H5N1 virus. J Med Virol 2001;63:242-6.  Back to cited text no. 38
Eapen CE, Nair SC. Potential danger of isolated platelet transfusion in patients with dengue infection. Indian J Med Res 2017;145:158-60.  Back to cited text no. 39
[PUBMED]  [Full text]  
Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020;395:473-5.  Back to cited text no. 40


  [Figure 1]

  [Table 1]

This article has been cited by
1 On Therapeutic Plasma Exchange Against Severe COVID-19-Associated Pneumonia: An Observational Clinical Study
Luca Cegolon, Behzad Einollahi, Yunes Panahi, Sina Imanizadeh, Mohammad Rezapour, Mohammad Javanbakht, Mohammad Nikpouraghdam, Hassan Abolghasemi, Giuseppe Mastrangelo
Frontiers in Nutrition. 2022; 9
[Pubmed] | [DOI]
2 Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southern India
Ramkumar Govindarajan,Ganesan Ramamoorthy,Revathy Marimuthu Shanmugam,Sumathi Bavanandam,Manimaran Murugesan,Chitra Shanmugam,Aravind Arumugam,Vaishnavi Priyaa Chellamuthu,Rajalakshmi Kandasamy Venkatraj,Kavitha Sampathkumar,Poppy Rejoice,Kandasamy Alias Kumar,Shafique Adamali,Kannan Mariappan,Ramani Rathnavel,Vijai Shankar Chidambara Manivasagam,Arulselvan Velusamy,Senthilvadivu Arumugam,Thasneem Taj Elikkottil,Anand Vimal Dev,Mousumi Sen,Alagammai Palaniappan,Allwin James Dorairaj,Chandan Kumar Kedarisetty,Jayanthi Venkataraman,Mugilan Karthikeyan,Aravindh Somasundaram,Arulraj Ramakrishnan,Vijaya Prakash Madesh,Joy Varghese,Dheeraj Kumar Anupa,Venkatakrishnan Leelakrishnan,Mukundan Swaminathan,Ravindra Kantamaneni,Jeyaraj Ubal Dhus,Natarajan Murugan,Kartik Natarajan,Caroline Selvi,Hemamala V. Saithanyamurthi,Ambily Nadaraj,Lakshmanan Jeyaseelan,Chundamannil Eapen Eapen
Indian Journal of Gastroenterology. 2021;
[Pubmed] | [DOI]
3 Von Willebrand factor: A key glycoprotein involved in thrombo-inflammatory complications of COVID-19
Shalki Choudhary,Kajal Sharma,Pankaj Kumar Singh
Chemico-Biological Interactions. 2021; : 109657
[Pubmed] | [DOI]
4 Targeting raised von Willebrand factor levels and macrophage activation in severe COVID-19: Consider low volume plasma exchange and low dose steroid
U. Zachariah,S.C. Nair,A. Goel,K.A. Balasubramanian,I. Mackie,E. Elias,C.E. Eapen
Thrombosis Research. 2020;
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Our Hypothesis
Support for the ...
Our Preliminary ...
Our Preliminary ...
High Von Willebr...
Plasma Exchange ...
Primary Versus S...
How Does Treatme...
Some Points to H...
Implications and...
How to Test the ...
Supplementary Ma...
Secondary Hemoph...
The Possible Lin...
Acute Failure of...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded522    
    Comments [Add]    
    Cited by others 4    

Recommend this journal