Plasma exchange in critically ill COVID-19 patients

Introduction: The spectrum of coronavirus disease 2019 (COVID-19) ranges from asymptomatic infection to respiratory failure and death of patients Severely affected patients may develop a cytokine storm-like clinical syndrome with multi-organ failure and a mortality rate of up to 90% Case Description: Here we report on five COVID-19 patients with a median age of 67 years who were treated at the intensive care unit due to respiratory failure Prophylactic antibiotic, antimycotic, and antiviral/immunomodulatory therapy was initiated in all patients upon admission During the course of the disease, patients developed circulatory shock and persistent fever together with increased interleukin 6-levels compatible with the cytokine storm-like clinical syndrome In addition, all patients had multi-organ failure with acute respiratory-distress syndrome (ARDS, 4 severe, 1 moderate) and acute kidney injury of at least KDIGO stage 2 A single PE with a median of 3 39 L of fresh frozen plasma was initiated in all patients followed by one additional treatment in patients 1, 3, and 5 During the PE, striking reduction of inflammatory markers C-reactive protein (-47%, P=0 0078) and interleukin 6 (-74%, P=0 0078), as well as significant reduction of ferritin (-49%, P=0 0078), LDH (-41%, P=0 0078), and D-Dimer (-47%, P=0 016) were observed Due to circulatory shock, four patients received vasopressor treatment at the start of the PE that could be substantially reduced during treatment (-71%, P=0 031) Biochemical and clinical improvement continued over the following days together with an increase in the oxygenation index in 4 out of 5 patients These improvements were achieved with only 1 to 2 PE, which might be a possible indication of a direct pathophysiological influence of PE on the COVID-19-associated cytokine storm-like clinical syndrome Three of the 5 most critically ill patients are alive, while a 71-year-old male and a 76-year-old female patient died after the therapy was limited due to persistent severe ARDS Discussion: PE improved inflammation, microcirculatory clot formation, and hypotension, thereby improving clinical outcomes Further studies to test whether (repeated) PE can alter the course of critically ill COVID-19 patients are clearly indicated