39/2016
Extracorporeal hemocorrection in patients with acute kidney injury and severe cardiac insufficiency

Denis V. Federiakin, M.A. Petrushin, A.V. Goncharuk Russian Healthcare Ministry Tver State Medical University, Tver City, Russia

Summary:

This case study reports on two patients with contrast-induced nephropathy (CIN; induced by usage of contrast cardio-vascular system radiologic imaging) and severe cardiac insufficiency (NYHA IV) after undergoing coronary angiography (acute coronary syndrome, Killip IV).

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Case presentation

  • Due to chronic cardiac insufficiency in the setting of ischemic heart disease (functional Class 3-4) and the administration of contrast agent symptoms of acute kidney injury occurred 6 hours after the procedure.
  • Both patients were hypervolemic (CVP 18±1,2 mmHg, ELWI 15±1 ml/kg)
  • Left ventricular ejection fraction (LVEF) decreased to 34±3% while respiratory index was at 250±15
  • This condition required artificial lung ventilation, renal replacement therapy and intensive catecholamine support
  • Due to clinical need for renal replacement therapy, elevated levels of inflammatory markers, and high need for catecholamines CytoSorb was additionally installed into the CRRT circuit

Treatment

  • CytoSorb was used in conjunction with a common dialysis machine (Multifiltrate; Fresenius Medical Care) run in CVVHDF mode
  • Ultrafiltrate volume was 2,500-3,000 ml per day
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Hemodynamics (MAP, cardiac index, GEDVI, ITBVI, EVLWI)
  • Inflammatory parameters (IL-6, IL-8, TNFα)
  • Renal function (creatinine, urea, electrolytes)

Results

  • Hemodynamics considerably improved during the course of the combined treatment; catecholamine support could be stopped while cardiac index increased by 30%, hypervolemia could be clearly reduced (CVP 8-9 mmHg, ELWI 8±1 ml/kg), left ventricular myocardial contractility improved with the ejection fraction increasing to 45%
  • Respiratory index also increased to 390±15 mmHg
  • Markers of inflammation could be significantly reduced: IL-6 and IL-8 decreased by 64% and 72%, respectively, TNFα decreased by 48% during the course of the treatment

Patienten Follow-Up

  • By day 3 of extracorporeal hemocorrection urine output restored, renal retention parameters decreased
  • After 7 days on ICU both patients were discharged to further therapy

CONCLUSIONS

  • Extracorporeal hemocorrection methods (CytoSorb + CRRT) in patients with contrast-induced nephropathy and cardiogenic shock in the setting of acute cardiac insufficiency (NYHA IV) could be viewed as an effective therapy method