On February 5, 2020 CytoSorbents Corporation (NASDAQ:CTSO), a critical care immunotherapy leader commercializing its CytoSorb blood purification technology to treat deadly inflammation in critically-ill and cardiac surgery patients around the world, reported the first published case report detailing the successful use of CytoSorb to help treat cytokine release syndrome (CRS) following the administration of CAR T-cell immunotherapy (Press release, Cytosorbents, FEB 5, 2020, View Source [SID1234553902]). In a recent publication entitled, "Multimodal Therapeutic Approach of Cytokine Release Syndrome Developing in a Child Given Chimeric Antigen Receptor-Modified T Cell Infusion", in the journal, Critical Care Explorations, a publication of the Society of Critical Care Medicine, Bottari and colleagues highlight the use of CytoSorb, in conjunction with continuous renal replacement and tocilizumab, to help treat a 14-year old boy with refractory acute lymphoblastic leukemia (ALL), who developed Grade 4 cytokine release syndrome (CRS) with progressive respiratory failure and severe acute respiratory distress syndrome (ARDS) following the administration of CAR T-cell immunotherapy.
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Dr. Joerg Scheier, Senior European Medical Director of CytoSorbents stated, "We are pleased to report the first published use of CytoSorb to assist in the rescue of a patient suffering from life-threatening cytokine release syndrome due to CAR T-cell immunotherapy. The combination of CytoSorb with continuous renal replacement therapy, and tocilizumab, was simple and safe to implement. More importantly, it led to a dramatic reversal of acute respiratory distress syndrome, one of the most deadly forms of lung injury that is a root cause of death in the Wuhan coronavirus outbreak, with a corresponding profound drop in cytokine storm and circulating inflammatory mediators. We believe this successful proof-of-concept treatment supports the consideration of this treatment regimen in future cases of CRS triggered by CAR T-cell immunotherapy."
This patient had previously failed treatment of his ALL with both chemotherapy and immunotherapy, and was enrolled into an academic CAR T-cell immunotherapy trial. However, 7 days after the CAR T-cell therapy infusion, he developed severe cytokine release syndrome (a form of cytokine storm), and the rapid progression of respiratory failure that did not respond to an initial dose of tocilizumab and low dose steroids. The patient was admitted to the pediatric intensive care unit (PICU) and placed on mechanical ventilation for profound ARDS with a PaO2/FiO2 (P/F) ratio of 45 mm Hg, and hemodynamic instability requiring vasopressors. His Grade 4 cytokine release syndrome (CRS) exhibited extremely high cytokine and inflammatory marker levels, including an IL-6 of 4,048 pg/mL and a ferritin of 146,095 ng/mL. The patient underwent five blood purification treatments with CytoSorb, changed every 12 hours for the first day, and then every 24 hours for the next 3 days, in conjunction with continuous renal replacement therapy (CRRT), with tocilizumab administered on the last 2 days of CytoSorb treatment. In the first 3 days of CytoSorb treatment, the ferritin levels dramatically decreased to normal, and the IL-6 dropped to 248 pg/mL. This improvement in control of CRS was mirrored by a gradual and progressive improvement in lung function, as measured by P/F ratio and chest X-rays. On day 12 of admission to the PICU, he was weaned off of mechanical ventilation and was discharged from the ICU a week later.
CAR T-cell immunotherapy (Kymriah – Novartis; Yescarta – Gilead) represents a breakthrough in cancer treatment of acute lymphocytic leukemia (ALL; also called acute lymphocytic leukemia) and Diffuse large B-cell lymphoma (DLBCL) that are refractory to standard biologic therapy and chemotherapy, and has great potential in other blood cancers and solid tumors in the future. The therapy takes a patient’s own immune T-cells, genetically modifies them outside of the body with a chimeric antigen receptor (CAR) to be able to recognize and kill the cancer cells, and reinfuses these CAR T-cells back into the body where they have led to dramatic cures of what were considered irreversibly fatal cancers. However, in doing so the activated cells often trigger an inflammatory response in the patient caused by the production of high levels of inflammatory mediators called cytokines. In some patients, the levels of these cytokines can spiral upwards, creating a "cytokine storm" or cytokine release syndrome (CRS) that can rapidly cause multi-organ failure, inflammation of the brain, and potentially death if left untreated. Tocilizumab (an IL-6 receptor antagonist) and intravenous steroids are the current approved treatments for CRS but are not always successful in controlling CRS or CRES, and have the potential to immune suppress the patient, increasing the risk of serious infection. CytoSorb has the potential to fill this gap. There are currently two approved CAR T-cell immunotherapies in both the United States and European Union. According to Market Research Future, the global CAR T-cell immunotherapy market is expected to approach $9 billion in revenue by 2025.