32/2016
Use of CytoSorb to prevent acute renal failure during drug intoxication-associated rhabdomyolysis

Dr. med. Murad Alkhani, Dr. Michael Rennicke, Dr. Klotilda Jahaj, Dr. Anna Semyonova, Dr. Irina Veil, Dr. Karem Suleiman, Dr. Changguang Shan, Prof. Dr. Rüdiger Becker | Internal Intensive Care Unit of the Medical Clinic I, Hospital Wolfsburg

Summary:

This case study reports on a 55-year-old female patient, found disoriented and poorly responsive at home who was subsequently brought to hospital by emergency ambulance.

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Case presentation

  • In the emergency room it was found that the patient had ingested 8 g of ibuprofen and 25 g of metamizol (~ 50 tablets) as well as potassium bromatum (amount unknown) in a suicidal intent in chronic depression
  • On admission the patient had plasma levels of creatine kinase (CK) of 32,383 U/L, myoglobin> 3,000 µg/L, CRP 48 mg/L and exhibited a drastically increased CK level > 127,100 U / L (out of range)  the next day, indicative for a drug-induced rhabdomyolysis
  • Patient was at any time hemodynamically and respiratory stable, renal function tests remained consistently within the normal range
  • Fluid Administration as well as of 8.4% sodium bicarbonate solution (~ 500 ml/day) to prevent myoglobin precipitation in  the renal tubuli level
  • Due to massive elevation of serum CK and myoglobin very quick decision to use CytoSorb in combination with renal replacement therapy with the rationale for the treatment of rhabdomyolysis-associated complications even before acute renal failure could establish

Treatment

  • Three consecutive CytoSorb treatments for a total treatment time of 72 hours (24 hours each)
  • CytoSorb was used in conjunction with a Octo Nova CRRT machine (Diamed; used hemofilter APS-18H from Asahi Kasei Medical Co., Ltd)
  • Anticoagulation: heparin (PTT guided administration)
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Rhabdomyolitic parameters (CK, myoglobin)
  • Inflammatory parameters (CRP)

Results

  • After the last treatment CK plasma concentrations were at 51.111 U/L, myoglobin 1.045 µg/L, both continuing to decline
  • While receiving treatment, there were no signs of acute renal failure at any time, the patient always showed good excretion and normal creatinine levels

Patienten Follow-Up

  • In the further course creatine kinase (4. 695 U/L) and myoglobin levels (936 µg/l) continued to decrease
  • Patient could be discharged in completely stable condition within a few days directly from intensive care to her home environment

CONCLUSIONS

  • The CytoSorb therapy proved as highly efficient in terms of the elimination of CK and myoglobin in this patient
  • According to the medical team, such patients with such a pronounced rhabdomyolysis are usually transferred to a university hospital, however due to the rapid response to CytoSorb therapy this was not necessary in the present case
  • An acute renal failure could be prevented by the early combined use of CytoSorb and renal replacement therapy
  • Safe, simple and extremely practical application of CytoSorb especially with the Octo Nova machine