Journal Information
Vol. 40. Issue. 4.July - August 2020
Pages 371-490
Vol. 40. Issue. 4.July - August 2020
Pages 371-490
Letter to the Editor
Open Access
Role of extended hemodialysis in COVID-19: a case report
Papel de la hemodiálisis extendida en COVID-19: a propósito de un caso
Francisco Valgaa,
Corresponding author

Corresponding author.
, Nicanor Vega-Diaza, Tania Monzonb, Fayna Gonzalez-Cabreraa, Adonay Santanaa, Eduardo Baamondea, Roberto Gallegoa, Juan Carlos Quevedo-Reinaa, José Carlos Rodriguez-Pereza
a Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
b Servicio de Nefrología, Centro de Hemodiálisis Avericum Negrín, Las Palmas de Gram Canaria, Spain
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Tables (1)
Table 1. Evolution of inflammatory parameters of the patient presented.
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Extended hemodialysis (HDx), with medium cut-off membranes, could favor the effective elimination of medium-sized molecules such as IL-6 and other inflammatory mediators.1 In the current literature, there are few reports on the use of these membranes in hemodialysis patients with SARS-CoV-2 infection, but their potential therapeutic effect is not described.2

We present the case of a 68-year-old man with a history of hypertension type 2 diabetes mellitus, congestive heart failure, sleep apnea-hypopnea syndrome, ischemic heart disease and chronic kidney disease stage G3a A3 according to 2012 KDIGO of probable diabetic etiology with serum basal creatinine values of 1.3–1.5 mg/dl.

He referred a recent trip to the SARS-CoV-2 risk area and came to the Hospital Emergency Department for a 24-h course of illness characterized by fever and associated dry cough. Nasopharyngeal exudate was performed, which was positive for SARS-CoV-2. On the day of admission to the hospital's Emergency Department (day 1), dyspnea to moderate efforts was added to the symptoms, so the patient was admitted to the hospital with subsequent, almost immediate, transfer to the Intensive Care Unit (ICU) due to torpid evolution. His respiratory symptoms are compatible with bilateral pneumonia complicated by acute respiratory distress syndrome and multi-organ failure: hypotension (mean arterial pressure of 60 mmHg), tachypnea, use of accessory musculature, and O2 saturation of 89% despite reservoir mask (FiO2 99%). The patients requires mechanical ventilation and inotropic drugs (norepinephrine and dopamine). In addition, it presents a situation of oliguria (10 mL/h) that initially responds to intravenous diuretics, presenting, in parallel, deterioration of renal function up to serum creatinine of 3.4 mg/dl, so on day 4 it is decided to start continuous venovenous hemofiltration (CVVH) that is maintained until day 26. He received treatment with hydroxychloroquine, azithromycin, lopinavir/ritonavir, interferon beta, ceftriaxone, levofloxacin, methylpredinisolone and heparin anticoagulation intermittently due to bleeding tendency. From day 21 to day 36, he received treatment with cloxacillin and cefepime, successively, due to the presence of methicillin- sensitive Staphylococcus aureus in the bronchial aspirate and worsening of the inflammatory parameters.

Since the patient has anasarca and persistent serum creatinine levels of 2 mg/dl and urea 162 mg/dl, intermittent hemodialysis with Theranova 400® 1.7 m2 filter was started (Baxter International Inc., Deerfield, IL, USA.) with a QB of 270−300 ml/min and a QD 500 mL/min, requiring only two sessions (days 36 and 38). Given the clinical improvement, her discharge from the ICU was decided on day 47 with serum creatinine levels of 1.3 mg/dl. The analytical parameters evolution is described in Table 1.

Table 1.

Evolution of inflammatory parameters of the patient presented.

  Day 1  Day 5  Day 9  Day 12  Day 16  Day 19  Day 22  Day 26  Day 30  Day 33  Day 36 (HD1)  Day 38 (HD2)  Day 40  Day 47 
Procalcitonin (ng/mL)  0.4 1          1.18  1.33  0.33  0.33  0.22  0.32  0.26    0.16 
PCR (mg/L)  22.63        11.45  7.97  29.16  23.32  134.62  165.25  145      14.05 
Ferritin (ng/mL)      2704.8              1505.2      1798   
LDH (U/L)  304      373    305    374    473  450    421   
AST (U/L)    281    79    42    36    16      22  21 
ALT (U/L)  17  26    35    81    46    29      2. 3  27 
GGT (U/L)    279    312    188    85    46      57  66 
Leukocytes (uL)  8590  4020  6980  14,700  12,200  18,390  18,800  15,000  17,700  20,700  9630  6640  6990  7780 
Neutrophils (uL)  6900  2770  5070  11,900  10,200  16,620  16,110  12,600  15,000  18,400  7860  488 0  4630  4950 
Lymphocytes (uL)  980  800  1050  1400  1050  680  670  1180  1540  1130  970  910  1530  1900 
Monocytes (uL)  690  410  710  1210  850  1070  1970  1030  970  970  520  430  490  650 
Hemoglobin (g/dl)  10.9  10.6  9.7  8.8  8.89  7.8  7.9  7.35  9.73  8.36  8.44  7.7  7.78  9.5 
Pl aquetas (uL)  154,000  96,700  93,000  121,000  310,000  424,000  332,000  228,000  130,000  126,000  157,000  187,000  244,000  374,000 
Fibrinogen (mg/dL)          116          571      355   
D-dimer (ug/mL)  1.69    5.56    5.59      4.47    5.37      5.51   
NLI  7.04  3.46  4.83  8.50  9.71  24.44  24.04  10.68  9.74  16.28  8.10  5.36  3.03  2.61 
PLI  157.14  120.88  88.57  86.43  295.24  623.53  495.52  193.22  84.42  111.50  161.86  205.49  159.48  196.84 
MLI  0.70  0.51  0.68  0.86  0.81  1.57  2.94  0.87  0.63  0.86  0.54  0.47  0.32  0.34 

HD1: first hemodialysis session; HD2: second hemodialysis session; MLR: monocyte-to-lymphocyte ratio; NLR: neutrophil-to- lymphocyte ratio; PLR: platelet-to-lymphocyte ratio

Taking into account the analysis before and after therapy, there is a tendency to a decrease in procalcitonin, C-reactive protein (PCR), the neutrophil-to-lymphocyte ratio (NLR) and the monocyte-to-lymphocyte ratio (MLR) (). In addition, there is an increase in the levels of platelets, lymphocytes and the platelet-lymphocyte ratio (PLR) (PLI), the antiphospholipid antibodies and lupus anticoagulant were negative. Neither IL-6 nor IL-1 levels were measured because no specific treatment to control these cytokines was started.

Currently, many aspects of the pathogenesis of SARS-CoV-2 infection are unknown. A “cytokine storm” has been proposed as one of the key aspects in the torpid course of some patients.3 Therefore, it has been considered, among others, the use of antagonists of IL-6 and IL-1 such as tocilizumab and anakinra respectively.3 Similarly, in sepsis, the effect that the use of high-permeability membranes could have on cytokine removal has been recognized.4

The HDx is a renal replacement therapy modality recognized for its high convection capacity and removal of medium-sized molecules (eg, cytokines) without further removal of albumin; but, unlike online hemodiafiltration, it maintains its effectiveness despite not having high QB, as is often the case in ICU patients with temporary catheters.1 Therefore, with a view to a possible SARS-CoV-2 outbreak in our hospital, we established a protocol in which, in cases such as the one described, we would use HDx using mediun cut-off membranes (Theranova®).

The PCR, neutrophil-to-lymphocyte, platelet-to-lymphocyte, and monocyte-to-lymphocyte ratios are parameters that have been shown to be useful as inflammation and prognostic markers in different entities, including in SARS-CoV-2 infection.5–7 In our patient, a trend towards improvement of these parameters can be seen parallel to the initiation of therapy, especially NLR and MLRI (Table 1). However, given that this is a single case and there are concomitants factors, such as the evolution of infection process itself, we cannot affirm that the effects obtained are attributable to the use of the aforementioned filter.

In conclusion, we consider that these findings should be taken into account for the design of larger studies and the use of these membranes could be considered, if they are available, due to their potential immunomodulatory effect, in patients requiring hemodialysis and affected by infection by SARS-CoV-2; especially at the beginning of stage III proposed by Siddiqi et al.8 when the inflammatory component is predominant.

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Please cite this article as: Valga F, Vega-Diaz N, Monzon T, Gonzalez-Cabrera F, Santana A, Baamonde E, et al. Papel de la hemodiálisis extendida en COVID-19: a propósito de un caso. Nefrologia. 2020;40:487–489.

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