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Angiotensin II treatment in COVID-19 patients: More risk than benefit? A single-center experience

: Heinicke, U.; Adam, E.; Sonntagbauer, M.; Knethen, A. von; Zacharowski, K.; Neb, H.

Fulltext ()

Critical care 24 (2020), Art. 409, 4 pp.
ISSN: 1364-8535
ISSN: 1466-609X
Journal Article, Electronic Publication
Fraunhofer IME ()

Critical care treatment of severely affected COVID-19 patients remains extremely challenging. To date, no experimental intervention has shown a significant benefit in this state of disease. Intravenous application of angiotensin II (ATII) has been postulated in cases with vasodilatory shock, as ATII is already known to be a very potent vasoconstrictor and has been used in patients suffering from septic shock [1]. To assess a potential deficiency of serum ATII, we used dipeptidyl-peptidase 3 (DPP3) levels, measurement provided by sphingotec (Nexus IB 10, sphingotec GmbH, Hennigsdorf, Germany), to guide ATII administration in severe COVID-19 patients. DPP3 is a ubiquitous peptidase that cleaves ATII enzymatically to angiotensin 4 and further to C-terminal tetrapeptide sequence. High serum level concentrations of DPP3 might lead to a lack of serum ATII and are also suggested to be a marker for cell death [2]. DPP3 levels elevated above 40 ng/ml are supposed to be associated with multi-organ failure and short-term death. We therefore initiated compassionate use treatment with ATII; initially four of in total six severe COVID-19 patients in vasodilatatory shock and DPP3 levels exceeding 40 ng/ml were treated with this strategy. Treatment of vasodilatatory shock prior to ATII infusion had been initiated with a combination of noradrenaline and vasopressin infusion. In all cases, the dosage of noradrenaline and vasopressin infusion was reduced after initiation of ATII infusion. However, the overall response rate was poor, as 3 of the first 4 patients died during or shortly after ATII administration. While one patient died due to severe intracerebral hemorrhage, one other died of a septic shock caused by mesenterial ischemia. The third patient died being in total multi-organ failure. After initial ATII use in distraught situations in these four patients, we hoped that initiation of ATII infusion in severe COVID-19 patients without massive vasodilatory shock might be favorable. However, after the death of another two patients (patients 5 and 6) with severe COVID-19 due to total respiratory failure, we abandoned ATII treatment in COVID-19 patients all together. Ethics committee approved the post hoc analysis of these data for scientific purposes.