Plasma exchange for COVID-19 thrombo-inflammatory disease

Nishkantha Arulkumaran; Mari Thomas; David Brealey; Ferras Alwan; Deepak Singh; Michael Lunn; Anna Welch; Samuel Clark; Eamon Raith; Ugan Reddy; Ryan Low; David Leverett; Mervyn Singer; Marie Scully

doi:10.1002/jha2.140

Plasma exchange for COVID-19 thrombo-inflammatory disease

EJHaem. 2020 Nov 30;2(1):26-32. doi: 10.1002/jha2.140. eCollection 2021 Feb.

Authors

Nishkantha Arulkumaran^{1

2}, Mari Thomas³, David Brealey^{1

2}, Ferras Alwan⁴, Deepak Singh⁵, Michael Lunn⁶, Anna Welch⁴, Samuel Clark¹, Eamon Raith⁶, Ugan Reddy⁶, Ryan Low⁴, David Leverett⁴, Mervyn Singer^{1

2}, Marie Scully³

Affiliations

¹ Intensive Care Unit University College London Hospitals NHS Foundation Trust London UK.
² Bloomsbury Institute of Intensive Care Medicine University College London London UK.
³ Department of Haematology University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UC BRC London UK.
⁴ Department of Haematology University College London Hospitals NHS Foundation Trust London UK.
⁵ Special Coagulation UCLH-HSL London UK.
⁶ National Hospital for Neurology and Neurosurgery University College London Hospitals NHS Foundation Trust London UK.

Abstract

Severe COVID-19 disease is a hyperinflammatory, pro-thrombotic state. We undertook plasma exchange (PEX) to determine its effects on organ function and thrombo-inflammatory markers. Seven critically ill adults with severe COVID-19 respiratory failure (PaO₂:FiO₂ ratio < 200 mm Hg) requiring invasive or noninvasive ventilatory support and elevated thrombo-inflammatory markers (LDH >800 IU/L and D-dimer >1000 μg/L (or doubling from baseline) received PEX, daily, for a minimum of 5 days. No other immunomodulatory medications were initiated during this period. Seven patients matched for age and baseline biochemistry were a comparator group. Coagulation screening revealed no evidence of coagulopathy. However, von Willebrand Factor (VWF) activity, antigen and VWF antigen: ADAMTS13 ratio, Factor VIII and D-dimers were all elevated. Following 5 days of PEX, plasma levels of all the above, and ferritin levels, were significantly reduced (P < .05) while lymphocyte counts normalized (P < .05). The P_aO₂:FiO₂ ratio increased from a median interquartile range (IQR) of 11.6 (10.8-19.7) kPa to 18.1 (16.0-25.9) kPa (P < .05). Similar improvements were not observed in controls. Acute kidney injury (AKI) occurred among five patients in the control arm but not in patients receiving PEX. PEX improved oxygenation, decreased the incidence of AKI, normalized lymphocyte counts and reduced circulating thrombo-inflammatory markers including D-Dimer and VWF Ag:ADAMTS13 ratio.

Keywords: COVID‐19; inflammation; lymphopenia; plasma exchange; thrombosis.