Application of CytoSorb in a case of infection-associated rhabdomyolysis

Sven Suefke, Friedhelm Sayk, Martin Nitschke, University Lübeck

Summary:

This case study reports on a 55-year-old patient with history of arterial hypertension who was admitted with complaints of dyspnea and symptoms of respiratory infection.

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Case presentation

  • Patient developed fulminant manifest pneumogenic sepsis and acute respiratory distress syndrome (ARDS) with massive requirements for fluids and catecholamines for hemodynamic stabilization
  • Drastically increased plasma concentrations of myoglobin and creatine kinase on top of his inflammatory response, indicative of massive infection-associated rhabdomyolysis
  • Generalized compartment syndrome due to fluid overloading, elevated creatinine levels and acute liver injury as evidenced by hyperbilirubinemia.
  • For treatment of his acute kidney injury grade III (crush kidney) and for negative fluid balancing, renal replacement therapy was initiated using a Genius device with an AV600S filter
  • To lower inflammatory mediator and myoglobin levels, CytoSorb was additionally installed

Treatment

  • Four consecutive sessions were run over periods of 20 hours each, separated from one another by a pause interval of 4 hours.
  • Blood flow rates were 150 ml/min
  • Anticoagulation was achieved using citrate.
  • The CytoSorb adsorber was placed in pre-dialyzer position.

Measurements

  • Laboratory: Myoglobin, Creatine kinase, C-reactive protein, IL-6, Procalcitonin, Creatinine, ALT, AST, Bilirubin, Leucocytes, Thrombocytes, Hct, Hb, Albumin, Glucose, Na/K
  • Clinical: Urine output

Results

  • During the course of the treatment, plasma concentrations of IL-6, procalcitonin, myoglobin and creatine kinase decreased significantly
  • Levels of leucocytes, thrombocytes, alanine aminotransferase, and aspartate aminotransferase normalized over the 4 consecutive treatments
  • The clinical situation improved considerably including improvement of the patient’s respiratory situation and liver function
  • Kidney function did not improve
  • The course of hematocrit, Hb and platelet count provided no evidence for a potential lack of hemo- or biocompatibility of the CytoSorb treatment
  • Antibiotic dosages did not have to be adjusted at any time

Patient Follow-Up

  • Kidney function remained impaired after a total of 5 days on CytoSorb
  • Patient was discharged at day 13 with ongoing renal failure and need for renal replacement therapy
  • Two days after the last treatment with CytoSorb the patient could be extubated without further complications

Conclusions

  • In this patient, the application of CytoSorb resulted in a significant reduction of cytokines (i.e. IL-6) but also had an important additive effect on myglobin removal
  • The effects seen in this patient are a sum of both adsorption techniques used (CVVH and CytoSorb)
  • It remains speculative to what extent the effects seen can be ascribed to the application of the Cytosorb adsorber and therefore needs to be investigated in future randomized controlled trials