Year : 2020 | Volume
: 18 | Issue : 3 | Page : 156--157
Role of plasma exchange in COVID-19
Professor of Intensive Care, The George Institute for Global Health, Sydney, Australia
Prof. Bala Venkatesh
The George Institute for Global Health, Sydney
|How to cite this article:|
Venkatesh B. Role of plasma exchange in COVID-19.Curr Med Issues 2020;18:156-157
|How to cite this URL:|
Venkatesh B. Role of plasma exchange in COVID-19. Curr Med Issues [serial online] 2020 [cited 2021 Sep 24 ];18:156-157
Available from: https://www.cmijournal.org/text.asp?2020/18/3/156/284738
The COVID-19 pandemic has resulted in >1.6 million infections and an associated crude mortality rate of 5.9%. It has placed an unprecedented demand on healthcare around the world, and in some countries, surges in infection rates have overwhelmed the capacity of health-care services. The ease of transmissibility, the rapidity of global spread, and a high number of deaths in the older population and those with comorbidities have, understandably, generated a lot of concern and anxiety among members of the public, health -care workers, and administrators about the appropriate way to manage the pandemic.
A substantial body of literature has provided detailed insight into mechanisms of disease – including the role of the angiotensin-converting enzyme 2 receptor, cytokine storm, macrophage activation, and a dysregulated immunological response. Capitalizing on this knowledge, several trials are underway to test the efficacy of antiviral agents, antimalarial agents, angiotensin receptor blockers, corticosteroids, and immune modulators.
In this context, a review article by Alexander et al. proposes that plasma exchange (PEX) and low-dose steroids may be potential therapies based on the observation that secondary hemophagocytic lymphohistiocytosis (sHLH) may be responsible for some of the deaths in adult patients with severe COVID-19. They report their experience of low-volume PEX with low-dose steroids in the treatment of adult patients with sHLH and acute liver failure caused by dengue virus and other nonviral triggers.
PEX has been used in clinical practice for a variety of conditions such as autoimmune diseases, Guillain–Barré syndrome and chronic polyneuropathy, and thrombotic thrombocytopenic purpura. The mechanism of action of PEX is based on the removal, for example, of pathogenic antibodies, complement fractions, clotting factors, immune complexes, and cytokines or other macromolecules in the plasma, or less frequently albumin-bound small molecules (drugs or toxins) that remain predominantly intravascular.
Is there biological plausibility that PEX may be of benefit in COVID-19? Multiple reports point to a cytokine storm in COVID-19, predominantly of pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6, which are cleared during PEX. Hyperferritinemia suggestive of macrophage activation has been reported in COVID-19. PEX has been tried with variable success in fulminant macrophage activation syndromes. COVID-19 has been reported to be associated with coagulopathy and elevated antiphospholipid antibodies, a condition amenable to PEX. A recent publication of recovery of patients with severe COVID-19 infection following the transfusion of convalescent plasma suggests the possibility that besides antibodies limiting viral replication, other plasma components may play a part. An in vitro study has demonstrated that lectin affinity plasmapheresis was able to clear lentivirus particles pseudotyped with MERS-CoV S-protein (another coronavirus) from body fluids. The coronavirus particle responsible for COVID-19 infection has a diameter of 60–100 nm-1, which is smaller than the pore size of PEX filters, and therefore, filtration of circulating viruses is possible.
Reports are emerging of the use of blood purification as rescue therapy in COVID-19. A small case series of 3 patients undergoing blood purification therapy for cytokine storm in COVID-19 has been published – one with PEX and the other two patients with oXiris adsorption system. Two of these patients survived.
However, any enthusiasm for the deployment of such therapies must be balanced against the risks. In addition to the recognized adverse effects associated with PEX, given its easy transmissibility, the risk of nosocomial infection needs to be considered. Moreover, transfusion-associated lung injury after PEX has been reported. In septic shock, a condition typically associated with cytokine storm, extracorporeal blood purification techniques have been shown to improve the hemodynamic status, but robust data from clinical trials showing improvements in outcome are lacking. Preliminary reports of improved respiratory function and reduction in immunological mediators in patients following blood purification therapies with ARDS secondary to varied etiologies,,, suggest a potential role for PEX, but large scale studies are required to assess the safety and efficacy.
Based on the currently available evidence, PEX cannot be recommended for the routine management of COVID-19 patients. Trials of convalescent plasma are being planned, but there are no registered trials of PEX in COVID-19 on clinicaltrials.gov. Further understanding of the pathobiology of COVID-19 coupled with clinical reports of rescue PEX will provide the foundations for the planning of future clinical trials of blood purification therapies in this disease.
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