First us case series: Continuous renal replacement therapy with adsorbent oxiris filter in the setting of COVID-19 infection

Introduction: Many COVID-19 hospitalized patients sustain acute kidney injury (AKI) requiring CRRT Multisystem hyperinflammatory response plays a large role in their infection leading to enhanced morbidity and filter clotting Oxiris filters have been used for years in Europe in septic patients due to their properties of reducing cytokines and inflammatory mediators but have not been available in the United States until late April 2020 Use of these filters in COVID-19 patients has been very limited, and has not yet been reported We report the first U S experience in 3 COVID-19 patients requiring mechanical ventilation for their respiratory failure and continuous venous to venous hemodiafiltration (CVVHDF) using oXiris dialyzers for their (AKI) Case Description: Case 1: A 73 year old male with laboratory tests revealing: creatinine 1 79mg/dl, C-Reactive Protein 1 01mg/dl, D-dimer 597, ferritin 13,000 ng/ ml and Interleukin-6 (IL-6) 96 pg/mL He was started on CVVHDF with M150 filter and then switched to oXiris filter He remained on oXiris CVVHDF for 9 days with no reported clotting events, a decline in ferritin by 90% to 1437ng/mL and a decline in IL-6 levels to 73 pg/mL Case 2: A 55 year old male on CVVHDF with the M150 filter had a serum ferritin level progressively increasing to 2377 ng/ml and multiple clotting events The dialyzer was switched to oXiris He had no clotting events while on CVVHDF for six days and his serum ferritin level decreased to 1759 ng/ml Case 3: A 40 year old male on extracorporeal membrane oxygenation (ECMO) He was initiated on CVVHDF to the ECMO circuit using a M150 filter for 7 days and was switched to oXiris filter with no reported clotting events thereafter Discussion: The COVID-19 cytokine storm leads to activation of pro-inflammatory mediators leading to severe morbidity including coagulopathic events Optimal treatment is still unknown ECMO and CVVHDF with oXiris dialyzer in critical COVID-19 infection may play a role in decreasing inflammatory markers, which confers overall clinical improvement Once switched to oXiris, our patients showed improvement in inflammatory markers and had no clotting of their dialyzers In these patients, convective clearances (CVVHDF) may be more beneficial than diffusive therapies (CVVHD)