key: cord-1030358-psnpp8y5 authors: Sandoval, Diego A; Rama, Inés; Quero, María; Hueso, Miguel; Gómez, Francisco; Cruzado, Josep M title: Treatment for Severe Coronavirus Disease 2019 with a biomimetic sorbent hemoperfusion device in patients on hemodialysis date: 2021-01-18 journal: Clin Kidney J DOI: 10.1093/ckj/sfab010 sha: d4505226cc59861925026a13cafc606a6937cf80 doc_id: 1030358 cord_uid: psnpp8y5 Hemodialysis patients present more morbidity and mortality risk in coronavirus disease 2019. In patients who may develop severe symptoms the process called “viral sepsis” seems to be a crucial mechanism. In those cases, the hemodialysis procedure provides an excellent tool to explore the benefit of some extracorporeal therapies. We reported the outcome of 4 hemodialysis patients with severe COVID-19 treated with Seraph(®)100 hemoperfusion device. Three of four cases presented a good clinical response after hemoperfusion. In conclusion, the treatment with Seraph(®)100 device may be a simultaneous treatment to improve the hemodialysis patients with severe SARS-CoV-2. on April 17th 2020 the United States Food and Drug Administration granted COVID-19 emergency use authorizations for the Seraph  100. This device has ultrahigh molecular weight polyethylene beads with end point-attached heparin 5 . Herein we describe the first 4 cases of HD patients with severe COVID-19 treated with Seraph  100 HP. The procedure consisted on 2 sessions of HP with Seraph  100 in parallel with standard HD performed in 2 consecutive days. The Seraph  100 was placed pre-dialyzer. Blood samples were taken to admission, at the start and the end of each HP and subsequent days of treatment until the patients were discharged. Patients selected for treatment were not candidates for intensive therapy. Table 1 summarizes the main characteristics of the 4 patients treated with HP. All patients were very old, had some comorbidities and criteria of bad prognosis and severe pulmonary involvement. The HP was started between day 2 and 13 after the symptomatology onset. All patients but patient 2 showed favorable outcome and were discharged. In patient 2 the HP was incompletely performed because of hemodynamic intolerance. Table 1 shows the evolution of some inflammatory and coagulation parameters during the HP procedure. Interestingly, comparing pre-HP with post-HP we did not observe a significant reduction in interleukin-6, ferritin and D-dimer. The decrease of these inflammatory parameters appeared after the 2 session HP protocol was completed in responder patients. The second peak increase of ferritin in patient 4 was related to secondary bacterial pneumonia that was successfully treated with antibiotics. COVID-19 direct viral attack on lung epithelial cells, lung capillary endothelial cells, vascular endothelial cells with high levels of ACE2 and T lymphocytes 2,3 may account for the severe inflammatory response, microcirculation dysfunction and prothrombotic state observed in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Theoretically, the reduction of viral load and/or some inflammatory mediators may alleviate the course of the disease. Seraph  100 is an HP device that mimics the endothelial cell glycocalyx that has an anti-thrombogenic, anti-inflammatory and pathogen immobilization effect by selective adsorption. Four hour in-vitro perfusion provides >99% reduction of HSV-1, HSV-2, Ebola, Zika, CMV and adenoviruses 5 . Also, COVID-19 and other coronaviruses bind to heparin and so it seems feasible that COVID-19 will bind to Seraph  100 sorbent. Patients on HD are particularly susceptible to infection by several mechanisms including deficient immune response. On the other hand, HD patients have an impaired glycocalyx barrier and sustained endothelial cell activation as mechanisms involved in viral shedding. Thus, increased viral shedding in combination with a deficient immune response may put HD patients on the worse clinical scenario. Actually, our patients on HD with COVID-19 showed a mortality rate of 23%. However, the dialysis session brings an excellent opportunity to perform simultaneous HP. Blood passes over exclusive microbeads coated with molecular receptor sites that mimic endothelial glycocalyx before entering the hemodialyzer. Herein, we reported the outcome of 4 HD patients with severe COVID-19 treated with Seraph  100. All patients had criteria of poor prognosis and were not suitable candidates to ICU management. Interestingly, we observed a good clinical response in 3 out of 4 cases. The patient 2 had a clinical worsening with intolerance to HP, dying 24 hours after second HP. As we did not observe reduction of inflammatory molecules during the 4hour hemoperfusion session, our hypothesis is that the HP beneficial effect could be mainly related to the viral load reduction. In this regard, it seems advisable to perform the HP earlier in the course of the disease (in 2 out of the 3 responders HP was performed in the first week). In conclusion, hemoperfusion with Seraph  100 during the first week after the onset of the disease may be a simultaneous treatment to improve the HD patients with severe SARS-CoV-2 although further studies should be performed. Coronavirus disease 2019 in chronic kidney disease SARS-CoV-2 and viral sepsis: observations and hypotheses Evaluation of Current Therapies for COVID-19 Treatment Heparin 2.0: A New Approach to the Infection Crisis We thank to colleagues who were involved in the care of the hemodialysis patients with COVID-19 and nursing team of the hemodialysis unit of our center. We also grateful with Cardiolink® for supplying the hemoperfusion devices. The authors of this manuscript have no conflicts of interest to disclose as described by the Clinical Kidney Journal.