CC BY
19
UDC 616-08
DOI: 10.24411/1995-5871-2020-10124
POSSIBILITIES OF USING EXTRACORPOREAL PHOTOCHEMIOIMMUNOTHERAPY IN THE TREATMENT OF PATIENTS WITH COVID-19
* S. Panov, S. Sarsenbayev, G. Omarov, A. Paltushev, A. Pavljukov, A. Rahmatulin
Military Clinical Hospital of the Ministry of Defense of the Republic of Kazakhstan, Almaty
SUMMARY
Against the background of the spread of a severe form of coronavirus infection, there are still no reliable methods of drug treatment. In this regard, extracorporeal methods of treatment are relevant. We are no exception. In their practice, in addition to the main treatment, extracorporeal photochemotherapy (EPCT) was used to treat patients with severe respiratory failure associated with coronavirus infection in the intensive care unit. As a result of the studies of the functional state of immunity, it was revealed that the developing endotoxicosis proceeds with secondary immunodeficiency and paralysis of the phagocytic function of neutrophils. The use of EPCT in the treatment of patients with coronavirus reliably solved the problem of endotoxicosis within 3 days, and the resulting immunodeficiency was resolved by 7 days. The methods used for assessing the functional state of immunity correlated with objective indicators of patients' well-being and, taking into account the ease of implementation, these laboratory studies can be used by doctors to predict the course of coronavirus infection.
Key words: critical care medicine, coronavirus disease 2019 pneumonia (COVID-19), apheresis, extracorporeal photopheresis, severe acute respiratory syndrome, assessment of the functional state of immunity, photochemioimmunotherapy.
The pathogenesis of highly pathogenic human coronavirus is still not completely understood. Cytokine storm and viral evasion of cellular immune responses are thought to play important roles in disease severity. Neutrophils were found in both the peripheral blood and lung of patients with SARS-CoV. The severity of lung damage correlated with extensive pulmonary infiltration of neutrophils and macrophages and higher numbers of these cells in the peripheral blood in patients with MERS. Neutrophils are the main source of chemokines and cytokines. The generation of cytokine storm can lead to ARDS, which is a leading cause of death in patients with severe acute respiratory syndrome [1]
The reason for the development of SARS is increased adhesion of primed neutrophils to the endothelium of the vessels of the pulmonary circulation. The accumulation of neutrophils in the capillaries of the lungs leads to an uncontrolled release of hydrogen peroxide not into the phagosome, but into the extracellular space. The oxygen-dependent
bactericidal systems of neutrophil and aggressive mediators of azurophilic granules are activated.
In vitro cell experiments show that delayed release of cytokines and chemokines occurs in respiratory epithelial cells, dendritic cells (DCs), and macrophages at the early stage of SARS-CoV infection. Later, the cells secrete low levels of the antiviral factors interferons (IFNs) and high levels of proinflammatory cytokines (interleukin (IL)-1P, IL-6, and tumor necrosis factor (TNF)) and chemokines (C-C motif chemokine ligand (CCL)-2, CCL-3, and CCL-5) [2].
This is due to the fact that SARS-CoV has very little sequence of CpG nucleotides. receptor system «friend or foe» CD-47 is not activated. CD289-TLR9 (toll-like receptors of grade 9), activation is slowed down. They are activated through other paths. When delayed by AER protease, TLR9 activates MuD88 and the ZAP component. They respond with uncontrolled anxiety to all immune cell systems.
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Edema in the lungs and other organs has long been noticed by clinicians when monitoring patients with COVID-19. It turned out that SARS-CoV indirectly inhibits the functioning of ENaC-a (a protein of the cell membranes of human epithelial cells) on the surface of the respiratory tract, which leads to impaired fluid reabsorption. As a result, it causes edema, endotheliitis and intravascular activation of platelets and neutrophils [3].
Primered neutrophils in patients with SARSdonotdie,duetoactivationandincreasing oxygen deficiency, apoptosis is delayed, which increases the likelihood of developing inflammatory syndromes. Negatively charged endothelial glycosaminoglycans support barrier function and protect lung tissue from neutrophil penetration. Enzymatic destruction of glycocalyx leads to exposure of the endothelium, which becomes available for the adhesion of neutrophils. Ischemia / reperfusion or pro-inflammatory cytokines such as IL-1B, TNF-a, IFN-y, and some bacterial and virus endotoxins make endothelium adhesive to circulating leukocytes. Slowing microcirculation in the lungs, the formation of platelet microaggregates leads to adhesion and activation of neutrophils, which penetrate into the interstitial space and lumen of the alveolis. The pathological effect on the lungs is exerted by the products of the complement cascade, which, by their appearance in the circulating blood, further increase the permeability of the membranes. All this causes bronchial spasm, spasm of the pulmonary veins and increases thrombus formation. Free radicals damage cell membranes and also destroy hyaluronic acid and the connective mass of connective tissue. A widespread damage to microvessels leads to the movement of water and protein into the interstitial space, which contributes to an increase in the outflow of tissue fluid rich in protein. The lymph flowing from the lungs is the concentration of protein in reaches the level of its content in the blood plasma. violation of the permeability of the alveolocapillary membrane develops non-cardiogenic pulmonary edema [4].
Remarks. In the treatment of patients with pneumonia and SARS caused by
coronovirus, antiviral drugs (oseltamivir phosphate), antibacterial (Antibacterial drug of the fluoroquinolone group, Third Generation Cephalosporine) and glucocorticoids are prescribed. These drugs do not solve the problem of pulmonary edema and lymphocytic immunodeficiency. WHO official information: "There are currently no vaccines or special pharmaceuticals available for COVID-19".
Objective: to evaluate the effectiveness of the use of extracorporal methods of photochemioimmune blood modification for pathogenetic links of COVID-19 - pneumonia.
Task to evaluate the effectiveness of blood photochemioimmunomodification in patients with COVID-19 - pneumonia located in the intensive care unit.
Materials and methods:
For the treatment of SARS-COVID-19, we suggest sampling 1(one) dose of blood, centrifuging blood at 2500 rpm 18 minutes, followed by plasma extraction to reduce the concentration of immune complexes, as well as modifying the cell membrane under conditions of increased gravity [5, 6, 7]. After plasma extraction under conditions of a laminar cabinet or box for sterile work, introduce immunomodulators, Sodium adenosintriphosphate solution for injections 1% in 2 ml + y-L-Glutamyl-L-cysteinylglycine-oxopentanoic acid (GSH) 300mg in 200 ml of a 0.9% solution of sodium chloride into the blood. Then, container with blood is sterile sealed and placed in a cabinet, maintaining temperature of 38 C and stirring possibility for 30 minutes. A packet of blood cells and a medicine is transfused to a patient with extracorporeal ultraviolet irradiation of blood in a special apparatus using the flow method. The procedure must be carried out 5 times every other day. Soft ultraviolet of halogen lamps does not affect the structure of chemicals, however, it leads to the modification of neutrophils and activation of T-lymphocytes.
Based on the recommendations of the Global Pandemic Consortium, we carried out photochemioimmunotherapy in 15 people (group №1) with severe respiratory failure due to coronavirus infection. The effectiveness
* vramin89@gmail.com
of the proposed method was assessed by the functional state of neutrophils using the NTS-test (test using nitro blue tetrazolium) and counting a part of active neutrophils [8]. Analysis of phagocytic activity of neutrophils used stimulation of neutrophils with latex. We counted the part of cells phagocytosing latex particles in a population of 100 neutrophils [9]. The state of endotoxicosis was determined by the level of middle molecules by the method of M. Malakhova [10]. These results of the function study were compared with the results of the functional activity of neutrophils in 15 patients of the control group (group №2) with coronavirus infection and manifestations of respiratory failure. In this group, extracorporeal detoxification methods were not used.
Results:
All patients in the intensive care unit had severe respiratory failure. oxygen saturation decreased to 76-80% against the background of respiratory support. lymphocytes and platelets in the blood found a pronounced decrease in 85% of cases. leukocytosis (1620 * 109 / l) was detected in 65% of cases.
all patients had an increased erythrocyte sedimentation rate (40-50 mm/h). Assessment of the functional state of neutrophils revealed a total depletion of reactive oxygen species in 79%. Agranulocytosis and paralysis of phagocytic function developed in 67%. The endotoxicosis index was above 1.3 units. In these patients, the condition was regarded as a manifestation of severe endotoxicosis with the development of secondary immunodeficiency with a defect in the neutrophil phagocytosis system. The results are shown in Table 1.
Symptomatic therapy in combination with photochemioimmunotherapy was carried out in 15 patients (group №1) in the intensive care unit. These patients showed clinical improvement 2-3 days after taking one infusion once daily.
After practicing this technol ogy, wefound the following results: a general improvement in clinical conditions, normalization of body temperature, a reduction in C Reactive Protein (PRC), normalization of heart rate, an improvement in saturation and reduction in oxygen support.
Table №1. Average values and medians of indicators of the percentage of active neutrophils and the percentage of neutrophils with phagocytic activity before the start of treatment and at
the end.
№ Name NTS test, % Phagocytic activity, %
Before After 7 days of Before After 7 days of
treatment treatment treatment treatment
1. group №1 17.8±27.1 (m = 79.7±13.3 (m = 24.1±24.2 (m = 62.6±18.2 (m =
±7.004) ±3.4) ±6.3) ±4.7)
2. group №2 16.3±13.7 (m = 31.3±15.2 (m = 22.9±26.6 (m = 31.7±16.3 (m =
±3.5) ±3.9) ±6.9) ±4.2)
Our observations showed that, against the background of the treatment, leukocytosis decreased, neutrophil granulocytes were restored, after 7 days of photochemioimmunotherapy, the proportion of active neutrophils significantly (p = 0.001) increased 4.4 times and averaged 79.7 ± 13.3%. The proportion of phagocytic neutrophils increased 2.6 times and averaged 62.6 ± 18.2%. The intoxication index decreased below 1.0 on day 3, and at the end of treatment, it was 0.3 + 0.08.
In the control group (group №2), changes in the proportion of active neutrophils occur during treatment, but the increase is less, no more than 2 times. at the time of transfer of patients from the intensive care unit to the general ward according to the functional assessment of blood, secondary immunodeficiency persists, but at the same time, with a morphological analysis of blood, leukocytosis may still persist.
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Conclusions and relevance:
Contrary to leukocytosis in the blood, patients with Coronavirus infection develop secondary immunodeficiency with paralysis of the phagocytic function of neutrophils and agranulocytosis. It is not possible to determine these violations by morphological methods. The use of technologically simple methods of NBT test and assessment of phagocytic activity allows a comprehensive approach to the diagnosis of immunity disorders in patients with coronavirus infection.
The use of methods photochemio immunotherapy reliably allows solving the problem with secondary immunodeficiency and paralysis of the phagocytic function of neutrophils. Stabilize the condition of critically ill patients faster and reduce their stay in the intensive care unit.
The technology of incubation of the entire cell mass with immunomodulators is a method that differs from conventional methods of immunocorrection in that the leukocytes during treatment with the immunomodulator are outside the control of factors that form in the patient's body and prevent cell activation in vivo, the drug is not administered directly to the patient, which eliminates adverse reactions and complications.
The practice of using this method has shown high efficiency (90% improvement) in usage of UBI in community-acquired pneumonia and is a non-drug correction method in Critical Care Medicine in our clinic.
Conflict of interests. The authors declare that there is no conflict of interests.
REFERENCES
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4. Sabirov D.M., Rosstal'naja A.L., Akalaev R.N., Sharipova V.H., Rosstal'naja M.L. Ostroe povrezhdenie legkih: spornye voprosy i nereshennye problemy // Zhurnal im. N.V. Sklifosovskogo «Neotlozhnaja medicinskaja pomoshh'». 2016. - №3. - S. 66-72.
5. Edelson R.L. Extracorporeal photopheresis // Trans. Am. Soc. Artif. Intern. Organs. 1984; Vol. 30; P. 674-675.
6. Cervio M., Scudeller L., Viarengo G. et al. Quality control on mononuclear cells collected for extracorporeal photochemotherapy: comparison between two UV-A irradiation devices // Vox Sang. 2015; Vol. 109, №4; P. 403-5.
^ 7. Kostyuchenko A.L. Efferentnaya terapiya. Pod red. A.L. Kostyuchenko. Spb.: Foliant,
8 2003. 432 pp.
^ 8. Viksman M.E., Majanskij A.N. Sposob ocenki funkcional'noj aktivnosti nejtrofilov
^ cheloveka po reakcii vosstanovlenija nitrosinego tetrazolija: Metod. rekomendacii. Kazan': Kazanskij NIIEM, 1979. 11 рр.
9. Dunn, P.A., and Tyrer, H.W. 1981. Quantitation of neutrophil phagocytosis, using 'I fluorescent latex beads: correlation of microscopy and flow cytometry. J. Lab. Clin. Med. 98: a 374-381.
§ 10. Malahova M. Jendogennaja intoksikacija kak otrazhenie kompensatornoj perestrojki
I obmennyh processov v organizme. Jefferentnaja ter. 2000; №4.
§ Панов С.А. ORCID ID 0000-0003-0596-8777; SPIN-код: 4554-3580
ВОЗМОЖНОСТИ ПРИМЕНЕНИЯ ЭКСТРАКОРПОРАЛЬНОЙ ФОТОХИМИОИММУННОТЕРАПИИ В ЛЕЧЕНИИ БОЛЬНЫХ СОУГО-19
* С.А. Панов, С.Е. Сарсенбаев, Г.Ж. Омаров, А.А. Палтушев, А.В. Павлюков, А.В. Рахматулин
Военный клинический госпиталь Министерства обороны Республики Казахстан, г. Алматы
АННОТАЦИЯ
На фоне распространения тяжелой формы короновирусной инфекции до сих пор не существует достоверных методов медикаментозного лечения. В связи с этим находит свою актуальность эфферентные методы лечения. Мы не стали исключением и в своей практике на пациентах с тяжелой дыхательной недостаточность на фоне короновирусной инфекции в отделении интенсивной терапии применили экстракорпоральную фотохимиотерапию (ЭКХТ). В результате проведенных исследований было выявлено, что на развивающийся эндотоксикоз протекает с вторичным иммунодефицитом и параличом фагоцитарной функции нейтрофилов. Применение ЭКХТ в лечении пациентов с короно-вирусом достоверно решало проблему эндотоксикоза в течение 3 дней, а возникающий иммунодефицит разрешался к 7 дню. Использованные методы оценки коррелировали с объективными показателями самочувствия пациентов и с учетом простоты выполнения, данные лабораторные исследования могут быть использованы врачами для прогностической оценки течения короновирусной инфекции.
Ключевые слова: реанимация, коронавирусная инфекция 2019, пневмония, ассоциированная COVID-19, аферез, экстракорпоральный фотоферез, тяжелый острый респираторный синдром, фотохимиоиммунотерапия.
ЭКСТРОКОРПОРАЛДЫ ФОТОХИМИЯЛЫК ИММУНОТЕРАПИЯНЫ СОУЮ -19 АУЬ^АН НАУКАСТАРДЫ ЕМДЕУДЕГ1 КОЛДАНУ МYМКIНДIКТЕРI
* С.А. Панов, С.Е. Сарсенбаев, * Г.Ж. Омаров, А.А. Палтушев, А.В. Павлюков, А.В. Рахматулин
^азакстан Республикасы ^органыс министрлшнщ Орталык эскери клиникалык госпитал^ Алматы к-сы
ТУЙ1НД1
Короновирустык инфекцияныц ауыр тYрiнiц таралуы кезшде дэрi дэрмекпен емдеудш накты эдiсi элi табылган жок. Осыган байланысты эфферентп емдеу ,eзектi эдютщ бiрi болып табылады. Бiз ез тэжiрибемiзде короновирустык инфекция аясын-да тыныс алуы киындап каркынды терапия бeлiмiнде ем алган пациенттерге экстра-корпоралды фотохимияны колдандык.Зерттеу нэтижесi агзада эндотоксикозбен бiрге иммуннодефициттш пайда болуын жэне нейтрофильдердш фагоцитоздык функциясыныц токтайтынын аныктады.Короновируспен ауырган наукастарды емдеу кезшде ЭКХТ- ны колдану эндотоксикоз мэселесш 3 кYн iшiнде шешсе , имун тапшылыгын 7 - шi кYнi жоюга мумкiндiк бердь^олданылган багалау эдiстерi пациенттердш жагдайыныц объективтi кeрсеткiштерiмен бiрiктiрiлген жэне iске асырудыц карапайымдылыгын ескере оты-рып, дэрiгерлер короновирустык инфекцияныц агымын болжау Yшiн осы зертханалык зерттеулердi колдана алады.
Юлт свздер: реанимация, коронавирустыц инфекция 2019, COVID-19-мен байланысты пневмония, аферез, экстракорпоральды фотоферез, ауыр жедел респираторлыц синдром, фотохемоиммунотерапия.
