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Forni L, Aucella F, Bottari G, Büttner S, Cantaluppi V, Fries D, Kielstein J, Kindgen-Milles D, Krenn C, Kribben A, Meiser A, Mitzner S, Ostermann M, Premuzic V, Rolfes C, Scharf C, Schunk S, Molnar Z, Zarbock A. Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force. BMC Nephrol 2024; 25:247. [PMID: 39085790 PMCID: PMC11293130 DOI: 10.1186/s12882-024-03679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/18/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Rhabdomyolysis describes a syndrome characterized by muscle necrosis and the subsequent release of creatine kinase and myoglobin into the circulation. Myoglobin elimination with extracorporeal hemoadsorption has been shown to effectively remove myoglobin from the circulation. Our aim was to provide best practice consensus statements developed by the Hemoadsorption in Rhabdomyolysis Task Force (HRTF) regarding the use of hemadsorption for myoglobin elimination. METHODS A systematic literature search was performed until 11th of January 2023, after which the Rhabdomyolysis RTF was assembled comprising international experts from 6 European countries. Online conferences were held between 18th April - 4th September 2023, during which 37 consensus questions were formulated and using the Delphi process, HRTF members voted online on an anonymised platform. In cases of 75 to 90% agreement a second round of voting was performed. RESULTS Using the Delphi process on the 37 questions, strong consensus (> 90% agreement) was achieved in 12, consensus (75 to 90% agreement) in 10, majority (50 to 74%) agreement in 13 and no consensus (< 50% agreement) in 2 cases. The HRTF formulated the following recommendations: (1) Myoglobin contributes to the development of acute kidney injury; (2) Patients with myoglobin levels of > 10,000 ng/ml should be considered for extracorporeal myoglobin removal by hemoadsorption; (3) Hemoadsorption should ideally be started within 24 h of admission; (4) If myoglobin cannot be measured then hemoadsorption may be indicated based on clinical picture and creatinine kinase levels; (5) Cartridges should be replaced every 8-12 h until myoglobin levels < 10,000 ng/ml; (6) In patients with acute kidney injury, hemoadsorption can be discontinued before dialysis is terminated and should be maintained until the myoglobin concentration values are consistently < 5000 ng/ml. CONCLUSIONS The current consensus of the HRTF support that adjuvant hemoadsorption therapy in severe rhabdomyolysis is both feasible and safe and may be an effective method to reduce elevated circulating levels of myoglobin.
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Affiliation(s)
- Lui Forni
- Critical Care Unit, Royal Surrey Hospital, Guildford, Surrey, UK.
- School of Medicine, University of Surrey, Kate Granger Building, Guildford, UK.
| | - Filippo Aucella
- "Casa Sollievo della Sofferenza" Foundation, Scientific Institut for Research and Health Care, Viale Cappuccini, 1, San Giovanni Rotondo (FG), 71013, Italy
| | - Gabriella Bottari
- Pediatric Intensive Care Unit, Bambino Gesu Children's Hospital, IRCCS, Rome, 00165, Italy
| | - Stefan Büttner
- Cardiology, Pulmonology, Nephrology and Intensive Care Medicine, Klinikum Aschaffenburg- Alzenau, Academic Teaching Hospital of Julius-Maximilians-University Würzburg, Aschaffenburg, Germany
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
- "Maggiore della Carità" University Hospital, via Gen. P. Solaroli 17, Novara, 28100, Italy
| | - Dietmar Fries
- Department for Anaesthesia and Critical Care Medicine, Medical University, Christoph-Probst- Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, Innsbruck, 6020, Austria
| | - Jan Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Naumburgstraße 15, D-38124, Braunschweig, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University, Moorenstr.5, D-40225, Duesseldorf, Germany
| | - Claus Krenn
- Clinic for Anaesthesia, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Wahringer Gurtel 18-20, Vienna, 1090, Austria
| | - Andreas Kribben
- Universitätsklinikum Essen (AöR) Nephrology Clinic, Medizinisches Zentrum, 2.104 Hufelandstraße 55, D-45147, Essen, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Saarland University Hospital, D-66424, Homburg, Germany
| | - Steffen Mitzner
- Fraunhofer IZI Rostock, Schillingallee 68, 18057, Rostock, Germany
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, London, SE1 9RT, UK
| | - Vedran Premuzic
- Department for Nephrology, Hypertension, Dialysis and Transplantation, School of Medicine, UHC Zagreb Croatia, University of Zagreb, Šalata ul. 2, Zagreb, 10000, Croatia
| | - Caroline Rolfes
- Department for Anesthesiology, Intensive Care Medicine, Pain Therapy and Emergency Medicine, GNH Klinikum Kassel, Mönchebergstraße 41-43, D-34125, Kassel, Germany
| | - Christina Scharf
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Geschwister-Scholl- Platz 1, D-80539, München, Germany
| | - Stefan Schunk
- Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Kirrberger Str. 100, D-66421, Homburg/Saar, Germany
| | - Zsolt Molnar
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, H-1082, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Collegium Maius, Fredry 10, Poznan, 61-701, Poland
- CytoSorbents Europe, Müggelseedamm 131, D-12587, Berlin, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
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Graf H, Gräfe C, Bruegel M, Zoller M, Maciuga N, Frank S, Weidhase L, Paal M, Scharf C. Myoglobin adsorption and saturation kinetics of the cytokine adsorber Cytosorb® in patients with severe rhabdomyolysis: a prospective trial. Ann Intensive Care 2024; 14:96. [PMID: 38907120 PMCID: PMC11192705 DOI: 10.1186/s13613-024-01334-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Rhabdomyolysis is a serious condition that can lead to acute kidney injury with the need of renal replacement therapy (RRT). The cytokine adsorber Cytosorb® (CS) can be used for extracorporeal myoglobin elimination in patients with rhabdomyolysis. However, data on adsorption capacity and saturation kinetics are still missing. METHODS The prospective Cyto-SOLVE study (NCT04913298) included 20 intensive care unit patients with severe rhabdomyolysis (plasma myoglobin > 5000 ng/ml), RRT due to acute kidney injury and the use of CS for myoglobin elimination. Myoglobin and creatine kinase (CK) were measured in the patient´s blood and pre- and post-CS at defined time points (ten minutes, one, three, six, and twelve hours after initiation). We calculated Relative Change (RC, %) with: [Formula: see text]. Myoglobin plasma clearances (ml/min) were calculated with: [Formula: see text] RESULTS: There was a significant decrease of the myoglobin plasma concentration six hours after installation of CS (median (IQR) 56,894 ng/ml (11,544; 102,737 ng/ml) vs. 40,125 ng/ml (7879; 75,638 ng/ml) (p < 0.001). No significant change was observed after twelve hours. Significant extracorporeal adsorption of myoglobin can be seen at all time points (p < 0.05) (ten minutes, one, three, six, and twelve hours after initiation). The median (IQR) RC of myoglobin at the above-mentioned time points was - 79.2% (-85.1; -47.1%), -34.7% (-42.7;-18.4%), -16.1% (-22.1; -9.4%), -8.3% (-7.5; -1.3%), and - 3.9% (-3.9; -1.3%), respectively. The median myoglobin plasma clearance ten minutes after starting CS treatment was 64.0 ml/min (58.6; 73.5 ml/min), decreasing rapidly to 29.1 ml/min (26.5; 36.1 ml/min), 16.1 ml/min (11.9; 22.5 ml/min), 7.9 ml/min (5.5; 12.5 ml/min), and 3.7 ml/min (2.4; 6.4 ml/min) after one, three, six, and twelve hours, respectively. CONCLUSION The Cytosorb® adsorber effectively eliminates myoglobin. However, the adsorption capacity decreased rapidly after about three hours, resulting in reduced effectiveness. Early change of the adsorber in patients with severe rhabdomyolysis might increase the efficacy. The clinical benefit should be investigated in further clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT04913298. Registered 07 May 2021, https//clinicaltrials.gov/study/NCT04913298.
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Affiliation(s)
- Helen Graf
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Caroline Gräfe
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Mathias Bruegel
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nils Maciuga
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sandra Frank
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Saxony, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
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Abu-Zidan FM, Jawas A, Idris K, Cevik AA. Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review. Turk J Emerg Med 2024; 24:67-79. [PMID: 38766416 PMCID: PMC11100580 DOI: 10.4103/tjem.tjem_11_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 05/22/2024] Open
Abstract
Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.
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Affiliation(s)
- Fikri M. Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ali Jawas
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Kamal Idris
- Department of Critical Care and the Intensive Care Unit, Burjeel Royal Hospital, Al-Ain, United Arab Emirates
| | - Arif Alper Cevik
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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de Fallois J, Scharm R, Lindner TH, Scharf C, Petros S, Weidhase L. Kidney replacement and conservative therapies in rhabdomyolysis: a retrospective analysis. BMC Nephrol 2024; 25:96. [PMID: 38486159 PMCID: PMC10938657 DOI: 10.1186/s12882-024-03536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome. METHODS This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves. RESULTS From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017). CONCLUSIONS This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too.
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Affiliation(s)
- Jonathan de Fallois
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Robert Scharm
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Tom H Lindner
- Medical Department III, Division of Nephrology, University of Leipzig Medical Center, Leipzig, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, Medical ICU, University of Leipzig Medical Center, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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Lu Y, Neyra JA. How I Treat Rhabdomyolysis-Induced AKI? Clin J Am Soc Nephrol 2024; 19:385-387. [PMID: 37934632 PMCID: PMC10937018 DOI: 10.2215/cjn.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/01/2023] [Indexed: 11/09/2023]
Affiliation(s)
- Yan Lu
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Ramírez-Guerrero G, Reis T, Marcello M, de Cal M, Ronco C. Crush syndrome-related acute kidney injury in earthquake victims, time to consider new therapeutical options? Int J Artif Organs 2024; 47:3-7. [PMID: 37589299 DOI: 10.1177/03913988231191954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Gonzalo Ramírez-Guerrero
- Critical Care Unit, Carlos Van Buren Hospital, Valparaíso, Valparaiso Region, Chile
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, Valparaíso, Valparaiso Region, Chile
- Department of Medicine, Universidad de Valparaíso, Valparaíso, Valparaiso Region, Chile
| | - Thiago Reis
- Deparment of Nephrology and Kidney Transplantation, Fenix Group, Sao Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
| | - Matteo Marcello
- International Renal Research Institute of Vicenza, (IRRIV Foundation), Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Massimo de Cal
- International Renal Research Institute of Vicenza, (IRRIV Foundation), Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, (IRRIV Foundation), Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
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Albrecht F, Schunk S, Fuchs M, Volk T, Geisel J, Fliser D, Meiser A. Rapid and Effective Elimination of Myoglobin with CytoSorb® Hemoadsorber in Patients with Severe Rhabdomyolysis. Blood Purif 2023; 53:88-95. [PMID: 37918366 DOI: 10.1159/000534479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/29/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Rhabdomyolysis is characterized by destruction of muscle fibers by various causes and is diagnosed by increased creatine kinase concentrations in the blood. Myoglobin released into the blood may cause acute kidney injury. In this randomized controlled study, we hypothesized that myoglobin elimination would be faster when a hemoadsorber was added to a continuous veno-venous hemodialysis (CVVHD). METHODS Four patients in the control group received CVVHD with a high cut-off hemofilter using high blood and dialysate flows for 48 h. Four patients in the CytoSorb group received the same treatment, but in addition, the hemoadsorber CytoSorb® was inserted in front of the hemofilter and replaced once after 24 h. Blood samples were drawn simultaneously before (pre) and after (post) the hemofilter or else the hemoadsorber, after 5 and 30 min, as well as after 2, 4, 8, and 24 h. All measurements were repeated the next day after the hemoadsorber had been renewed in the CytoSorb group. Primary outcome was the area under the curve (AUC) of the relative myoglobin concentrations as percent of baseline. To evaluate the efficacy of myoglobin removal, relative reductions in myoglobin concentrations during one passage through each device at each time point were calculated. RESULTS Patients in the CytoSorb group had a significantly lower AUC during the first 24 h (42 ± 10% vs. 63 ± 6%, p = 0.029) as well as during the observation period of 48 h (26 ± 7% vs. 51 ± 12%, p = 0.029). The relative reductions for myoglobin were considerably higher in the CytoSorb group compared to the control group during the first 8 h. CONCLUSION Myoglobin concentrations declined considerably faster when CytoSorb was added to a CVVHD. When compared to a high-cut-off hemofilter, efficacy of CytoSorb in myoglobin elimination was much better. Because of saturation after 8-12 h an exchange may be necessary.
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Affiliation(s)
- Frederic Albrecht
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Stefan Schunk
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Maren Fuchs
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Juergen Geisel
- Department of Clinical Chemistry and Laboratory Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Danilo Fliser
- Department of Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Gräfe C, Liebchen U, Greimel A, Maciuga N, Bruegel M, Irlbeck M, Weidhase L, Zoller M, Paal M, Scharf C. The effect of cytosorb® application on kidney recovery in critically ill patients with severe rhabdomyolysis: a propensity score matching analysis. Ren Fail 2023; 45:2259231. [PMID: 37728069 PMCID: PMC10512801 DOI: 10.1080/0886022x.2023.2259231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
Severe rhabdomyolysis frequently results in acute kidney injury (AKI) due to myoglobin accumulation with the need of kidney replacement therapy (KRT). The present study investigated whether the application of Cytosorb® (CS) led to an increased rate of kidney recovery in patients with KRT due to severe rhabdomyolysis. Adult patients with a myoglobin-concentration >10,000 ng/ml and KRT were included from 2014 to 2021. Exclusion criteria were chronic kidney disease and CS-treatment before study inclusion. Groups 1 and 2 were defined as KRT with and without CS, respectively. The primary outcome parameter was independence from KRT after 30 days. Propensity score (PS) matching was performed (predictors: myoglobin, SAPS-II, and age), and the chi2-test was used. 35 pairings could be matched (mean age: 57 vs. 56 years; mean myoglobin: 27,218 vs. 26,872 ng/ml; mean SAPS-II: 77 vs. 76). The probability of kidney recovery was significantly (p = .04) higher in group 1 (31.4 vs. 11.4%, mean difference: 20.0%, odds ratio (OR): 3.6). Considering patients who survived 30 days, kidney recovery was also significantly (p = .03) higher in patients treated with CS (61.1 vs. 23.5%, mean difference: 37.6%, OR: 5.1). In conclusion, the use of CS might positively affect renal recovery in patients with severe rhabdomyolysis. A prospective randomized controlled trial is needed to confirm this hypothesis.
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Affiliation(s)
- Caroline Gräfe
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | | | - Nils Maciuga
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Mathias Bruegel
- Institute of Laboratory Medicine, LMU hospital, Munich, Germany
| | | | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU hospital, Munich, Germany
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Boparai S, Lakra R, Dhaliwal L, Hansra RS, Bhuiyan MAN, Conrad SA, Krishnan P. Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study. Cureus 2023; 15:e39748. [PMID: 37398832 PMCID: PMC10310893 DOI: 10.7759/cureus.39748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Rhabdomyolysis is a serious condition that can cause acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Total plasma exchange (TPE) has been used as a treatment modality to clear myoglobin, but the evidence is limited. In this study, we aim to investigate the use of TPE in critically ill rhabdomyolysis patients. METHODS We retrospectively chart reviewed adult patients admitted to the intensive care unit (ICU) with a diagnosis of rhabdomyolysis between 2012 and 2021. We dichotomized patients into two groups based on whether TPE was used or not in addition to standard care. PRISMA machines with TPE2000 filters and either 5% albumin or fresh frozen plasma were used in the TPE group. RESULTS The patients' age ranged from 23 years to 87 years (mean 49.4, SD 18.1), and 51% were male. Initial creatinine ranged from 0.6 to 16mg/dL (mean 3.4, SD 2.7), creatinine phosphokinase (CPK) from 403-93,232 U/L, and myoglobin from 934 to >20,000. The Sequential Organ Failure Assessment (SOFA)scores on admission ranged from 6 to 17 (mean 7.23, SD 3.40). Overall, 28.78% (N=19) of the patients received therapeutic plasma exchange. The overall mortality in our study was 31.9%, with the length of ICU stay ranging from 1-25 days (mean 7.10, SD 5.91) among survivors. Older age and the presence of shock were predictive of mortality in univariate and multivariate analyses. There was no statistically significant association in mortality between the TPE and non-TPE groups (36.84% in TPE vs. 36.17% in the non-TPE group, OR 0.7209, p=0.959). Only two patients in the non-TPE group developed CKD/ESRD on long-term follow-up. CONCLUSION Our study showed that TPE administration in critically ill patients with rhabdomyolysis did not improve mortality or length of ICU stay. Further studies are required to elucidate its indication and effect on long-term renal outcomes.
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Affiliation(s)
- Sukhmani Boparai
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Rachaita Lakra
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Lovekirat Dhaliwal
- Internal Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Rajkamal S Hansra
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | | | - Steven A Conrad
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
| | - Prathik Krishnan
- Pulmonary and Critical Care Medicine, Louisiana State University (LSU) Health Shreveport, Shreveport, USA
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Zhou Z, Kuang H, Wang F, Liu L, Zhang L, Fu P. High cut-off membranes in patients requiring renal replacement therapy: a systematic review and meta-analysis. Chin Med J (Engl) 2023; 136:34-44. [PMID: 36848147 PMCID: PMC10106154 DOI: 10.1097/cm9.0000000000002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Whether high cut-off (HCO) membranes are more effective than high-flux (HF) membranes in patients requiring renal replacement therapy (RRT) remains controversial. The aim of this systematic review was to investigate the efficacy of HCO membranes regarding the clearance of inflammation-related mediators, β2-microglobulin and urea; albumin loss; and all-cause mortality in patients requiring RRT. METHODS We searched all relevant studies on PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure, with no language or publication year restrictions. Two reviewers independently selected studies and extracted data using a prespecified extraction instrument. Only randomized controlled trials (RCTs) were included. Summary estimates of standardized mean differences (SMDs) or weighted mean differences (WMDs) and risk ratios (RRs) were obtained by fixed-effects or random-effects models. Sensitivity analyses and subgroup analyses were performed to determine the source of heterogeneity. RESULTS Nineteen RCTs involving 710 participants were included in this systematic review. Compared with HF membranes, HCO membranes were more effective in reducing the plasma level of interleukin-6 (IL-6) (SMD -0.25, 95% confidence interval (CI) -0.48 to -0.01, P = 0.04, I2 = 63.8%); however, no difference was observed in the clearance of tumor necrosis factor-α (TNF-α) (SMD 0.03, 95% CI -0.27 to 0.33, P = 0.84, I2 = 4.3%), IL-10 (SMD 0.22, 95% CI -0.12 to 0.55, P = 0.21, I2 = 0.0%), or urea (WMD -0.27, 95% CI -2.77 to 2.23, P = 0.83, I2 = 19.6%). In addition, a more significant reduction ratio of β 2 -microglobulin (WMD 14.8, 95% CI 3.78 to 25.82, P = 0.01, I2 = 88.3%) and a more obvious loss of albumin (WMD -0.25, 95% CI -0.35 to -0.16, P < 0.01, I2 = 40.8%) could be observed with the treatment of HCO membranes. For all-cause mortality, there was no difference between the two groups (risk ratio [RR] 1.10, 95% CI 0.87 to 1.40, P = 0.43, I2 = 0.0%). CONCLUSIONS Compared with HF membranes, HCO membranes might have additional benefits on the clearance of IL-6 and β 2-microglobulin but not on TNF-α, IL-10, and urea. Albumin loss is more serious with the treatment of HCO membranes. There was no difference in all-cause mortality between HCO and HF membranes. Further larger high-quality RCTs are needed to strengthen the effects of HCO membranes.
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Affiliation(s)
- Zhifeng Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Huang Kuang
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Fang Wang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Lu Liu
- Preventive Medicine, West China School of Public Health, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Zhang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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11
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Mand N, Donath C, Leonhardt A, Weber S, Kömhoff M. Case report: Rhabdomyolysis in children in acute and chronic disease-a challenging condition in pediatric emergency medicine. Front Pediatr 2023; 11:1070465. [PMID: 36969298 PMCID: PMC10034202 DOI: 10.3389/fped.2023.1070465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/17/2023] [Indexed: 03/29/2023] Open
Abstract
Rhabdomyolysis is a challenging condition in pediatric emergency departments (PED): It ranges from asymptomatic illness with isolated elevation of creatine kinase (CK) levels to a life-threatening condition associated with extreme elevations in CK, electrolyte imbalances, circulatory failure (CF), acute kidney injury (AKI), and multi-organ disease. Most common causes of rhabdomyolysis are viral myositis and trauma, hereditary metabolic myopathies must be considered when facing rhabdomyolysis in early childhood. We report two cases of severe rhabdomyolysis with CF in our PED, thereby summarizing first-line management of rhabdomyolysis.
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Affiliation(s)
- N. Mand
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
- Correspondence: N. Mand
| | - C. Donath
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - A. Leonhardt
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - S. Weber
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - M. Kömhoff
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
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12
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Masolitin SV, Magomedov MA, Kim TG, Tyurin IN, Smetanina VM, Kalinin EY, Protsenko DN. Use of Selective Hemosorption and Hemodiafiltration in a Patient with Toxic Rhabdomyolysis Complicated by Acute Kidney Injury. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-6-78-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | - M. A. Magomedov
- N. I. Pirogov City Clinical Hospital no. 1; Pirogov Russian National Research Medical University
| | - T. G. Kim
- N. I. Pirogov City Clinical Hospital no. 1
| | - I. N. Tyurin
- Kommunarka Moscow Multidisciplinary Clinical Center; Pirogov Russian National Research Medical University
| | | | | | - D. N. Protsenko
- Kommunarka Moscow Multidisciplinary Clinical Center; Pirogov Russian National Research Medical University
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13
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Rhabdomyolysis-Induced AKI (RIAKI) Including the Role of COVID-19. Int J Mol Sci 2022; 23:ijms23158215. [PMID: 35897810 PMCID: PMC9329740 DOI: 10.3390/ijms23158215] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 01/08/2023] Open
Abstract
Rhabdomyolysis is a compound disease that may be induced by many factors, both congenital and acquired. Statin therapy is considered one of the most common acquired factors. However, recent scientific reports suggest that serious complications such as rhabdomyolysis are rarely observed. Researchers suggest that, in many cases, side effects that occur with statin therapy, including muscle pain, can be avoided with lower-dose statin therapy or in combination therapy with other drugs. One of the most recent agents discovered to contribute to rhabdomyolysis is COVID-19 disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Rhabdomyolysis is defined as a damage to striated muscle cells with escape of intracellular substances into the bloodstream. These substances, including myoglobin, creatine kinase (CK), potassium, and uridine acid, are markers of muscle damage and early complications of rhabdomyolysis. Symptoms may be helpful in establishing the diagnosis. However, in almost 50% of patients, they do not occur. Therefore, the diagnosis is confirmed by serum CK levels five times higher than the upper limit of normal. One of the late complications of this condition is acute kidney injury (AKI), which is immediately life-threatening and has a high mortality rate among patients. Therefore, the prompt detection and treatment of rhabdomyolysis is important. Markers of muscle damage, such as CK, lactate dehydrogenase (LDH), myoglobin, troponins, and aspartate aminotransferase (AST), are important in diagnosis. Treatment of rhabdomyolysis is mainly based on early, aggressive fluid resuscitation. However, therapeutic interventions, such as urinary alkalinization with sodium bicarbonate or the administration of mannitol or furosemide, have not proven to be beneficial. In some patients who develop AKI in the course of rhabdomyolysis, renal replacement therapy (RRT) is required.
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14
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Xiao L, Ran X, Zhong Y, Le Y, Li S. Serum creatine kinase levels are not associated with an increased need for continuous renal replacement therapy in patients with acute kidney injury following rhabdomyolysis. Ren Fail 2022; 44:893-901. [PMID: 35611437 PMCID: PMC9154772 DOI: 10.1080/0886022x.2022.2079523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Severe rhabdomyolysis can lead to acute kidney injury (AKI). Previous studies have reported a benefit from continuous renal replacement therapy (CRRT) for rhabdomyolysis-associated AKI. Here, we investigated the potential for serum creatine kinase (CK) levels to be used as a marker for CRRT termination in patients with AKI following rhabdomyolysis. We compared different CK levels in patients after CRRT termination and observed their clinical outcomes. We retrospectively collected 86 cases with confirmed rhabdomyolysis-associated AKI, who were receiving CRRT in Tongji Hospital. Patients’ renal functions were assessed within 24 h of intermission, patients with urine output ≥ 1,000 mL and serum creatinine ≤ 265 umol/L were considered for CRRT termination. After termination, 33 patients with a CK > 5,000 U/L were included in an experimental group, and 53 patients with a CK < 5,000 U/L were included in a control group. Clinical outcomes were compared between the two groups. Higher CK levels, as well as worse renal functions, predicted the necessity of CRRT. After CRRT termination, the in-hospital mortality (p = 0.389) and Multiple Organ Dysfunction Syndrome (MODS) incidence (p = 0.064) were similar between the two groups, while the experimental group showed a significantly shorter in-hospital length of stay (p = 0.026) and Intensive Care Unit (ICU) length of stay (p = 0.038). CRRT termination may be independent of CK levels for patients with rhabdomyolysis-associated AKI, and this is contingent on their renal functions having recovered to an appropriate level.
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Affiliation(s)
- Luniu Xiao
- Tongji Medical College of Huazhonng University of Science and Technology, Wuhan, China
| | - Xiao Ran
- Tongji Medical College of Huazhonng University of Science and Technology, Wuhan, China.,Department of Intensive Care Unit of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yanxia Zhong
- Tongji Medical College of Huazhonng University of Science and Technology, Wuhan, China
| | - Yue Le
- Tongji Medical College of Huazhonng University of Science and Technology, Wuhan, China
| | - Shusheng Li
- Tongji Medical College of Huazhonng University of Science and Technology, Wuhan, China.,Department of Intensive Care Unit of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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15
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Ferrari F, Husain-Syed F, Milla P, Lorenzin A, Scudeller L, Sartori M, Gramaticopolo S, D'Auria L, Guglielmi A, Cornara P, De Rosa S, Zanella M, Corradi V, De Cal M, Danzi V, Giavarina D, Brendolan A, Mojoli F, Arpicco S, Ronco C. Clinical Assessment of Continuous Hemodialysis with the Medium Cutoff EMiC®2 Membrane in Patients with Septic Shock. Blood Purif 2022; 51:912-922. [PMID: 35263746 DOI: 10.1159/000522321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION At the time of renal replacement therapy, approximately 20% of critically ill patients have septic shock. In this study, medium cutoff (MCO) continuous venovenous hemodialysis (CVVHD) was compared to high-flux membrane continuous venovenous hemodiafiltration (CVVHDF) in terms of hemodynamic improvement, efficiency, middle molecule removal, and inflammatory system activation. METHODS This is a monocenter crossover randomized study. Between December 31, 2017, and December 31, 2019, 20 patients with septic shock and stage 3 acute kidney injury (AKI) admitted to 2 Italian ICUs were enrolled. All patients underwent CVVHD with Ultraflux® EMiC®2 and CVVHDF with AV1000S® without washout. Each treatment lasted 24 h. RESULTS Compared to AV1000S®-CVVHDF, EMIC®2-CVVHD normalized cardiac index (β = -0.64; p = 0.02) and heart rate (β = 5.72; p = 0.01). Interleukin-8 and myeloperoxidase removal were greater with AV1000S®-CVVHDF than with EMiC®2-CVVHD (β = 0.35; p < 0.001; β = 0.43; p = 0.03, respectively). Leukocytosis improved over 24 h in EMiC®2-CVVHD-treated patients (β = 4.13; p = 0.03), whereas procalcitonin levels decreased regardless of the modality (β = 0.89; p = 0.01) over a 48-h treatment period. Reduction rates, instantaneous plasmatic clearance of urea, creatinine, and β2-microglobulin were similar across modalities. β2-Microglobulin removal efficacy was greater in the EMiC®2 group (β = 0-2.88; p = 0.002), while albumin levels did not differ. Albumin was undetectable in the effluent in both treatments. DISCUSSION In patients with septic shock and severe AKI, the efficacy of uremic toxin removal was comparable between MCO-CVVHD and CVVHDF. Further, MCO-CVVHD was associated with improved hemodynamics. Fraction of filtration and transmembrane pressure reduction and the maintenance of equal efficacy might be the key features of CVVHD with MCO membranes in critically ill patients.
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Affiliation(s)
- Fiorenza Ferrari
- Department of Anesthesia and Intensive Care Unit, I.R.C.C.S., San Matteo Hospital and University of Pavia, Pavia, Italy.,International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Faeq Husain-Syed
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Paola Milla
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigia Scudeller
- Research and Innovation Unit, I. R.C.C.S., Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Sartori
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Silvia Gramaticopolo
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigi D'Auria
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Angelo Guglielmi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Pietro Cornara
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Massimo De Cal
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Davide Giavarina
- Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia Arpicco
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Padua, Italy
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16
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Sigrist K, Winkler J, Westphalen A, Yuen B. [Citrus paradisi (grapefruit)-a negative interaction with a statin]. Med Klin Intensivmed Notfmed 2022; 117:168-171. [PMID: 34989821 DOI: 10.1007/s00063-021-00893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Katja Sigrist
- Klinik für Innere Medizin, Spital Bülach, Spitalstrasse 24, 8180, Bülach, Schweiz.
| | - Johanna Winkler
- Klinik für Innere Medizin, Spital Bülach, Spitalstrasse 24, 8180, Bülach, Schweiz
| | - Andrea Westphalen
- Interdisziplinäre Intensivstation, Spital Bülach, 8180, Bülach, Schweiz
| | - Bernd Yuen
- Interdisziplinäre Intensivstation, Spital Bülach, 8180, Bülach, Schweiz
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17
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Svobodová E, Drábek T, Brodská H. Pervitin Intoxication with Two-peak Massive Myoglobinemia, Acute Kidney Injury and Marked Procalcitonin Increase Not Associated with Sepsis. Prague Med Rep 2022; 123:266-278. [PMID: 36416465 DOI: 10.14712/23362936.2022.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Patients intoxicated with methamphetamine-like substances may present with myoglobinuria but rarely require admission. An 18-year-old female was admitted due to intoxication with pervitin, a methamphetamine derivative. She presented with an altered mental status, fever, and increased heart and respiratory rates. Biomarkers showed leukocytosis and markedly increased procalcitonin levels, suggestive of sepsis. However, blood cultures and infectious disease workup were unrevealing. Clinical course was heralded by rhabdomyolysis and myoglobinuria resulting in multi-organ failure including respiratory failure necessitating mechanical ventilation, hemodynamic compromise with need for inotropic support, and an acute renal failure requiring renal replacement therapy. Surprisingly, after a transient improvement, an unexpected second peak of myoglobin was observed on hospital day 5, controlled by intensifying the elimination methods, and administration of dantrolene. Acute kidney injury resolved by hospital day 15, and the patient could be discharged on day 22. While most patients with intoxications are discharged within 24 hours from emergency departments without being admitted, our case report highlights that the organ injury may evolve beyond the usual observation period, traditional renal-replacement therapies may not be sufficient to mitigate myoglobinemia with resulting acute kidney injury, and that procalcitonin may not be a reliable biomarker of infection in the setting of drug-induced rhabdomyolysis.
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18
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Xu Q, Jiang B, Li J, Lu W, Li J. Comparison of CVVH and CVVHDF on filter lifespan and solute removal - a randomized controlled trial. Ther Apher Dial 2021; 26:1030-1039. [PMID: 34967496 DOI: 10.1111/1744-9987.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study aimed to investigate whether Continuous Veno-Venous Hemodiafiltration (CVVHDF) has a different filter lifespan and molecular solutes clearance when compared to Continuous Veno-Venous Hemofiltration (CVVH). METHODS Sixty patients were enrolled in this study and randomly assigned to the CVVHDF (n=30) or CVVH (n=30) groups. Demographics, laboratory tests, urea, creatinine, IL-6, β2-microglobulin, and myoglobulin clearance were recorded. RESULTS Patients in the CVVH group had a shorter median time of filter lifespan compared with those in the CVVHDF group (20 vs 37.5 hours, p = 0.002). Urea and creatinine clearance were not significantly different between groups over time (p >0.05). IL-6, β2-microglobulin, and myoglobulin clearance were higher in the CVVH group. The transmembrane pressure (TMP) was significantly higher in the CVVH group. CONCLUSION The use of CVVHDF may lead to a longer filter lifespan and lower clearance of medium and large molecules without affecting the small molecular solute clearance.
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Affiliation(s)
- Qiancheng Xu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Bo Jiang
- Department of Critical Care Medicine, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Juan Li
- Department of Nephrology, The Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Weihua Lu
- Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, Anhui, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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19
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Tsujimoto Y, Miki S, Shimada H, Tsujimoto H, Yasuda H, Kataoka Y, Fujii T. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2021; 9:CD013330. [PMID: 34519356 PMCID: PMC8438600 DOI: 10.1002/14651858.cd013330.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment. OBJECTIVES This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT. DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications. AUTHORS' CONCLUSIONS The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Sho Miki
- Department of Nephrology, Sumitomo Hospital, Osaka, Japan
| | - Hiroki Shimada
- Department of Nephrology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama-shi, Japan
| | - Yuki Kataoka
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoko Fujii
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
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20
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Liu C, Chi K, Geng X, Hong Q, Mao Z, Huang Q, Liu D, Wang Y, Zhang Y, Zhou F, Cai G, Chen X, Sun X. Exogenous Biological Renal Support Improves Kidney Function in Mice With Rhabdomyolysis-Induced Acute Kidney Injury. Front Med (Lausanne) 2021; 8:655787. [PMID: 34124093 PMCID: PMC8193099 DOI: 10.3389/fmed.2021.655787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Rhabdomyolysis (RM) is a clinical syndrome characterized by breakdown of skeletal muscle fibers and release of their contents into the circulation. Myoglobin-induced acute kidney injury (AKI) is one of the most severe complications of RM. Based on our previous research, exogenous biological renal support alleviates renal ischemia–reperfusion injury in elderly mice. This study aimed to determine whether exogenous biological renal support promotes renal recovery from RM-induced AKI and to preliminarily explore the mechanisms involved. Methods: A parabiosis animal model was established to investigate the effects of exogenous biological renal support on RM-induced AKI. Mice were divided into three groups: the control group (in which mice were injected with sterile saline), the RM group (in which mice were injected with 8 mL/kg glycerol), and the parabiosis + RM group (in which recipient mice were injected with glycerol 3 weeks after parabiosis model establishment). Blood samples and kidney tissue were collected for further processing 48 h after RM induction. Bioinformatics analysis was conducted via Gene Ontology analysis, Kyoto Encyclopedia of Genes and Genomes pathway analysis, functional enrichment analysis, and clustering analysis. Results: No mice died within 48 h after the procedure. Exogenous biological renal support attenuated the histological and functional deterioration in mice with RM-induced AKI. Bioinformatics analysis identified key pathways and proteins involved in this process. We further demonstrated that exogenous biological renal support ameliorated AKI through multiple mechanisms, including by suppressing the complement system; attenuating oxidative stress, inflammation, and cell death; and increasing proliferation. Conclusions: Exogenous biological renal support provided by parabiosis can improve renal function in RM-induced AKI by suppressing the complement system; decreasing oxidative stress, inflammation, and cell death; and promoting tubular cell proliferation. Our study provides basic research evidence for the use of bioartificial kidneys to treat RM-induced AKI.
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Affiliation(s)
- Chao Liu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Kun Chi
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaodong Geng
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Quan Hong
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China.,State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Qi Huang
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Liu
- Department of Nephrology, Air Force Medical Center, People's Liberation Army (PLA), Beijing, China
| | - Yiqin Wang
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Ying Zhang
- Department of Ultrasound, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Guangyan Cai
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiangmei Chen
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xuefeng Sun
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center for Kidney Diseases, Chinese People's Liberation Army (PLA) Institute of Nephrology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
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21
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Gubensek J, Persic V, Jerman A, Premru V. Extracorporeal myoglobin removal in severe rhabdomyolysis with high cut-off membranes-intermittent dialysis achieves much greater clearances than continuous methods. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:97. [PMID: 33750390 PMCID: PMC7941698 DOI: 10.1186/s13054-021-03531-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Jakob Gubensek
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia. .,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia.
| | - Vanja Persic
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Alexander Jerman
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia
| | - Vladimir Premru
- Center for Acute and Complicated Dialysis, Department of Nephrology, University Medical Center Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia
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22
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Lumlertgul N, Hall A, Camporota L, Crichton S, Ostermann M. Clearance of inflammatory cytokines in patients with septic acute kidney injury during renal replacement therapy using the EMiC2 filter (Clic-AKI study). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:39. [PMID: 33509215 PMCID: PMC7845048 DOI: 10.1186/s13054-021-03476-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/20/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The EMiC2 membrane is a medium cut-off haemofilter (45 kiloDalton). Little is known regarding its efficacy in eliminating medium-sized cytokines in sepsis. This study aimed to explore the effects of continuous veno-venous haemodialysis (CVVHD) using the EMiC2 filter on cytokine clearance. METHODS This was a prospective observational study conducted in critically ill patients with sepsis and acute kidney injury requiring kidney replacement therapy. We measured concentrations of 12 cytokines [Interleukin (IL) IL-1β, IL-1α, IL-2, IL-4, IL-6, IL-8, IL-10, interferon (IFN)-γ, tumour necrosis factor (TNF)-α, vascular endothelial growth factor, monocyte chemoattractant protein (MCP)-1, epidermal growth factor (EGF)] in plasma at baseline (T0) and pre- and post-dialyzer at 1, 6, 24, and 48 h after CVVHD initiation and in the effluent fluid at corresponding time points. Outcomes were the effluent and adsorptive clearance rates, mass balances, and changes in serial serum concentrations. RESULTS Twelve patients were included in the final analysis. All cytokines except EGF concentrations declined over 48 h (p < 0.001). The effluent clearance rates were variable and ranged from negligible values for IL-2, IFN-γ, IL-1α, IL-1β, and EGF, to 19.0 ml/min for TNF-α. Negative or minimal adsorption was observed. The effluent and adsorptive clearance rates remained steady over time. The percentage of cytokine removal was low for most cytokines throughout the 48-h period. CONCLUSION EMiC2-CVVHD achieved modest removal of most cytokines and demonstrated small to no adsorptive capacity despite a decline in plasma cytokine concentrations. This suggests that changes in plasma cytokine concentrations may not be solely influenced by extracorporeal removal. TRIAL REGISTRATION NCT03231748, registered on 27th July 2017.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK. .,Division of Nephrology and Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. .,Critical Care Nephrology Research Unit, Chulalongkorn University, Bangkok, Thailand.
| | - Anna Hall
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK.,Zorgsaam Terneuzen, Rotterdam, The Netherlands
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK
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23
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Scharf C, Liebchen U, Paal M, Irlbeck M, Zoller M, Schroeder I. Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:41. [PMID: 33509234 PMCID: PMC7844984 DOI: 10.1186/s13054-021-03468-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rhabdomyolysis is frequently occurring in critically ill patients, resulting in a high risk of acute kidney injury (AKI) and potentially permanent kidney damage due to increased myoglobin levels. The extracorporeal elimination of myoglobin might be an approach to prevent AKI, but its molecular weight of 17 kDa complicates an elimination with conventional dialysis membranes. Question of interest is, if myoglobin can be successfully eliminated with the cytokine adsorber Cytosorb® (CS) integrated in a high-flux dialysis system. METHODS Patients were included between 10/2014 and 05/2020 in the study population if they had an anuric renal failure with the need of renal replacement therapy, if CS therapy was longer than 90 min and if myoglobin level was > 5.000 ng/ml before treatment. The measurement times of the laboratory values were: d-1 = 24-36 h before CS, d0 = shortly before starting CS and d1 = 12-24 h after starting CS treatment. Statistical analysis were performed with Spearman's correlation coefficient, Wilcoxon test with associated samples and linear regression analysis. RESULTS Forty-three patients were included in the evaluation (median age: 56 years, 77% male patients, 32.6% ECMO therapy, median SAPS II: 80 points and in-hospital mortality: 67%). There was a significant equilateral correlation between creatine kinase (CK) and myoglobin at all measurement points. Furthermore, there was a significant reduction of myoglobin (p = 0.03, 95% confidence interval (CI): - 9030, - 908 ng/ml) during CS treatment, with a median relative reduction of 29%. A higher median reduction of 38% was seen in patients without ongoing rhabdomyolysis (CK decreased during CS treatment, n = 21). In contrast, myoglobin levels did not relevantly change in patients with increasing CK and therefore ongoing rhabdomyolysis (n = 22, median relative reduction 4%). Moreover, there was no significant difference in myoglobin elimination in patients with and without ECMO therapy. CONCLUSION Blood purification with Cytosorb® during high-flux dialysis led to a significant reduction of myoglobin in patients with severe rhabdomyolysis. The effect might be obscured by sustained rhabdomyolysis, which was seen in patients with rising CK during treatment. Prospective clinical trials would be useful in investigating its benefits in avoiding permanent kidney damage.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
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24
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Rauch S, Borgato A, Gruber E, Leggieri C, Bock M, Seraglio PME. Case Report: Prevention of Rhabdomyolysis-Associated Acute Kidney Injury by Extracorporeal Blood Purification With Cytosorb ®. Front Pediatr 2021; 9:801807. [PMID: 35141180 PMCID: PMC8819180 DOI: 10.3389/fped.2021.801807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/29/2021] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury (AKI) is a severe complication of rhabdomyolysis. The pathophysiology of rhabdomyolysis-associated AKI is complex, but myoglobin related damage plays a major role. Extracorporeal removal of myoglobin is therefore an appealing target to prevent AKI, however, attempts to remove myoglobin with standard dialysis membranes have so far been disappointing. Here we report the case of a 12-year-old boy with severe trauma-related rhabdomyolysis where we successfully utilized continuous renal replacement therapy in combination with Cytosorb® to eliminate myoglobin and prevent AKI. The early use of extracorporeal myoglobin removal with Cytosorb® after severe rhabdomyolysis might be an option and should be further investigated as a tool to prevent the development of AKI.
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Affiliation(s)
- Simon Rauch
- Department of Anesthesia and Intensive Care Medicine, "F. Tappeiner" Hospital, Merano, Italy.,Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Andrea Borgato
- Department of Anesthesia and Intensive Care Medicine, "F. Tappeiner" Hospital, Merano, Italy
| | - Ewald Gruber
- Department of Surgery, "F. Tappeiner" Hospital, Merano, Italy
| | - Carlo Leggieri
- Department of Anesthesia and Intensive Care Medicine, "F. Tappeiner" Hospital, Merano, Italy
| | - Matthias Bock
- Department of Anesthesia and Intensive Care Medicine, "F. Tappeiner" Hospital, Merano, Italy.,Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
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