33/2017
Use of CytoSorb in acute renal failure due to multifactorial rhabdomyolysis

Dr. med. Cai Schelo, Dr. med. Maren Grothe, Dr. med. Meinhard Sauer St. Martinus Hospital Olpe, Medical Clinic - Department for Nephrology and Dialysis

Summary:

This case study reports on a 44-year-old male patient, who was initially admitted mentally altered, drowsy and with multiple contusion marks to a peripheral hospital. After initial diagnosis he was immediately transferred to our hospital via a rescue helicopter.

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Case presentation

  • The patient was a known multiple drug abuser with long-term heroin abuse and hepatitis C infection who had multiple bruises due to questionable falls/brawls
  • The initial diagnostic and therapeutic interventions in the peripheral hospital included a CT scan of the brain showing mild cerebral edema, laboratory diagnostics (creatinine 8.7 mg/dl, creatine kinase (CK) 130,000 U/l). Infusion  therapy was started but there was no need for surgical intervention for the injuries
  • Due to the lack of dialysis facilities, the patient was transferred to our clinic a few hours later completely overhydrated, confused, uncooperative and was immediately transferred to the intensive care unit where he had to be restrained and sedated
  • Diagnosis of severe anuric renal failure and initiation of intermittent hemodialysis
  • Patient was hemodynamically and respiratory stable at all times, however he exhibited  extremely elevated rhabdomyolysis and retention parameters (CK> 130,000 U/L, lactate dehydrogenase (LDH) 3672 U/L, glutamate oxalacetate transaminase (GOT) 651 U/L creatinine 9.4 mg/dl, urea 174 mg/dl) and an increased troponin T (142 pg / ml) and CRP (19.5 mg / dl), indicative of rhabdomyolysis from multifactorial genesis (trauma and intoxication)
  • After 24 hours and due to a significant increase in CK and persistent anuric renal failure, decision made to switch to continuous renal replacement therapy in combination with CytoSorb

Treatment

  • Four consecutive CytoSorb treatments with a total treatment time of 96 hours (24 hours each)
  • CytoSorb was used in conjunction with CRRT (Prismaflex, Gambro)
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Rhabdomyolisis parameters (creatine kinase, lactate dehydrogenase, glutamate-oxalacetate-transaminase)
  • Retention parameters (creatinine)
  • Inflammatory parameters (CRP)

Results

  • Rapid decrease in rhabdomyolysis parameters under CytoSorb therapy: reduction of CK to 16,000 U/L after 24 hours, 24 hours later to 11,000 U/l, after another 24 hours (6,000 U/l) and 48 hours (day 5) 3000 U/l
  • LDH and GOT also reduced during the course of the 4 treatment cycles (LDH from 3672 U/l to 2176 U/l within the first 10 hours and to 828 U/l after the last treatment, GOT of initially 651 U/l to 378 U/l within the first 10 hours and to 91 U/l after the last CytoSorb treatment)
  • Significant reduction of CRP from 19.5 to 0.8 mg/dl during the 4 treatments
  • Increase of creatinine to peak levels of 9.8 mg/dl within the first 5 days of treatment (presumably due to severe muscle breakdown)

Patient Follow-Up

  • As a result of the still high creatinine values, 2 further intermittent hemodialysis session were necessary
  • CK further decreased to within the normal range (200 U/l) on discharge
  • Normalization of the impaired fluid balance and establishment of sufficient spontaneous diuresis
  • Patient discharged within a few days back to a normal ward of the peripheral hospital in generally stable condition

CONCLUSIONS

  • CytoSorb represents an effective treatment option for the treatment of rhabdomyolysis
  • The removal of non-dialyzable molecular muscle proteins as the trigger molecules for renal failure (crush kidney) resulted in the rapid resolution of acute renal failure with onset of spontaneous diuresis within a few days and an improvement in the overall clinical condition
  • Safe, simple and practical application of CytoSorb