Pilot Study on HA380 Column Use in Critically Ill Patients Receiving Extracorporeal Support.

The role of inflammation in the pathophysiology of major organ dysfunction in critically ill patients is well established and this correlates with the degree of organ dysfunction which consequently may require increased level of organ support in the intensive care unit. Critically ill patients present in a spectrum of inflammatory states and on the extreme end of this spectrum are patients requiring renal replacement therapy and ECMO support. This subgroup of critically ill patients have been found to have high mortality.

The concept of attenuating severe hyperinflammatory response is sometimes used in certain disease states using agents such as intravenous corticosteroids, plasma exchange and more recently, anti-cytokine monoclonal antibodies. However, these strategies are associated with side effects (e.g. Bleeding and increased risk of infection), and are not necessarily appropriate in all critically ill patients with severe inflammation. Studies investigating the efficacy of these strategies have failed to show any clinical benefit except in the setting of COVID 19 infection.1-4 Early use of cytokine adsorption devices may provide an alternative non- pharmacological pathway with fewer side effects which can be deployed early.

The most studied cytokine adsorption device is the CytoSorb column which consists of biocompatible polymer sorbent beads. Several studies have demonstrated a reduction in vasopressor requirements, IL-6 levels, and Sequential Organ Failure Assessment (SOFA) scores.5,6 However, this observation did not translate into outcome benefit. There is considerable heterogeneity in how the cytokine adsorption is delivered in these studies and the study designs. An international registry analysis did not demonstrate a mortality benefit with CytoSorb either.7

The HA380 column consists of styrene divinylbenzene copolymers. In a recent study consisting of patients undergoing cardio-pulmonary bypass, patients who received the HA 380 column required lower vasopressor doses, shorter duration of invasive mechanical ventilation and had a shorter ICU length of stay.8 A direct in- vitro comparison of the CytoSorb device and the HA 380 device shows that the latter is less efficient at removing cytokines compared to the CytoSorb device but both devices were efficient at removing pro-inflammatory cytokines.9 The role of cytokines in critical illness is a double-edged sword10, and this may well be where CytoSorb may have a disadvantage - providing higher cytokine clearance for a longer period.

We hypothesise that the HA380 column use in critically ill patients with inflammation receiving renal replacement therapy or ECMO is associated with an improvement in mortality. It is recommended to be used early (within 72 hours of commencement of extracorporeal support). HA380 hemoperfusion cartridge, mainly adsorbs molecules from 10 to 60 kDa. Because of the accurate 3D macroporous structure and over 54000 m2 adsorption surface area of the resin.HA380 haemoperfusion therapy can provide a new regimen in controlling inflammatory cytokines storm. Studies have demonstrated the ability of the HA380 column to reduce the concentration of pro-inflammatory cytokines IL-1, TNF-alpha. 11,12

The aim of this feasibility pilot is to assess the feasibility of the early use of the HA380 cytokine adsorption column in a study and its effect on the time-to-liberation from extracorporeal membrane oxygenation (ECMO) support, vasoactive drug requirement and duration of vasoactive therapy, and mortality (or clinical surrogates for all-cause mortality).

Inclusion criteria

• Consent obtained
• Male or Female, aged 18 years - 65 years.
• Admitted with a diagnosis of sepsis (according to sepsis-3 definition), trauma, ARDS of infectious or non-infectious aetiology, trauma or after major surgery
• Need for extracorporeal support and specifically renal replacement therapy (RRT) and/or ECMO.
• Vasopressor or inotropic therapy requirement at the time of RRT or ECMO support
• Within 72 hours of requiring extracorporeal support
• At least one of:
• CRP > 100 mg/L (in the absence of immunosuppressive therapy/immunomodulation)
• Lactate >2 mmol/L

Exclusion criteria

• The participant may not enter the trial if ANY of the following apply:
• Unable to obtain consent.
• Expected to die in the next 24 hours.
• Pre-existing chronic kidney disease - requiring dialysis /eGFR < 30ml/min/1.73m2
• Pre-existing severe respiratory failure - e.g., requiring home oxygen/ home nebulisers/ poor exercise tolerance
• Chronic heart failure - NYHA class III and above
• Pregnancy
• Requirement for immediate immune modulation e.g., plasma exchange, high dose steroids , IV immunoglobulins (does not include vasoplegic dose of steroids or immune modulation for COVID 19)
• Participants who have participated in another research trial involving an investigational product in the past 12 weeks.