PREVENTION OF RENAL FAILURE –DUE TO RHABDOMYOLYSIS xxx
A CASE REPORT USING CYTOSORB xi
CLAUS-GEORG KRENN / 16. III. 2015
1st INTERNAT. CYTOSORB USER MEETING 2015
CONFLICT OF INTEREST
CGK 2012
CGK 2014
- STRATEGIES TO IMPROVE OUTCOME –
PATIENT IDENTIFICATION
IDENTIFICATION
&
RISK STRATIFICATION
… despite SOPs, bundles and guidelines, treatment differs between individuals and centers …
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
BENCHMARK
CGK 2013
- OUTLINE OF MY CASE (S)
MANAGEMENT OF RHABDOMYOLYSIS
„clinical syndrome characterized by injury to sceletal muscle fibres with
disruption and release of their content to circulation ...
increasing creatinine phosphokinase (CK), lactated dehydrogenase (LDH) and myoglobin levels in serum“
ICU ADMISSION RATE: up to 80%
systemic complications: disseminated intravascular coagulopathy (DIC)
electrolyte shift (cardiac dysrythmias) metabolic acidosis,
hypotension/shock, renal failure
1st INTERNAT. CYTOSORB USER MEETING 2015
CGK 2013
- OUTLINE OF MY CASE (S)
MANAGEMENT OF RHABDOMYOLYSIS
treatment of underlying cause (sepsis)
intense hydration with cristalloids, maintainance of polyuria
alkalinisation of urine (pH 6,5 – 7,0) ??
use of (osmotic) diuretics ??
close monitoring of renal function
RENAL REPLACEMENT THERAPYRonco C., Crit Care 2005: 9:141
Brochard L., Am J Resp Crit Care Med 2010; 181: 1128
Petejova N., Crit Care 2014; 18:224
1st INTERNAT. CYTOSORB USER MEETING 2015
INFLAMMATION, SIRS and SEPSIS CGK 2013
INFLAMMATION, SIRS and SEPSIS CGK 2013
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
Rimmelé T, Kellum JA, Anesthesiology. 2012 Jun;116(6):1377-87
ADJUVANT THERAPEUTIC OPTIONS DURING INFLAMMATION AND INFECTION
REGAIN CONTROL ON THE xx
CYTOKINE STORM WITH CYTOSORB TM
Source Images: Valenti, I “Characterization of a Novel Sorbent Polymer for the Treatment of Sepsis” 2008
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
EFFECTS ON ORGAN DYSFUNCTION BY CYTOSORB TM
Peng ZY, Carter MJ, Kellum JA: “Effects of hemoadsorption on cytokine removal and short term survival in rats”,
Crit Care Med (2008) 36(5): 1573‐7.
CytoSorb™‐reduces organ injury as shown by the decreased release of:
HMGB‐1(protein indicative for cell injury)
ALT (protein indicative for liver cell injury)
Creatinine (marker of kidney dysfunction)
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
EFFECTS ON ORGAN DYSFUNCTION BY CYTOSORB TM
Peng ZY, Carter MJ, Kellum JA: “Effects of hemoadsorption on cytokine removal and short term survival in rats”,
Crit Care Med (2008) 36(5): 1573‐7.
Development of severe kidney and liver tissue injury could be attenuated in the CytoSorb™‐treated group
LIVERCytosorb Control
KIDNEYCytosorb Control
SAFETY STUDIES
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
all of the 100 patients were included into safety‐analysis
in more than 300 treatments there were no adverse and device‐related events;
total number of safe treatments > 650
no significant changes of electrolyte levels or increase of organ dysfunctions
minimal loss of albumin and usual loss of thrombocytes
no activation of the complement‐System
D Schädler, et al ; Critical Care 2013, 17 (Suppl 2): P62
SAFETY STUDIES
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
CASE REPORT RHABDOMYOLYSIS / CYTOSORB TM
Kuntsevich VI et al., In‐Vitro Myoglobin Clearance by a Novel Sorbent System; Artificial Cells, Blood Substitutes, and Biotechnology. 2009;37: 45‐47
UNIVERSITY VIENNA CYTOSORBTM EXPERIENCE
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013
CASE REPORT / CYTOSORB TM
Figure 1:decrease of myoglobin levels during cytosorb™ application (1st run: 0‐6hours; 2nd run: 9‐14hours)
Application of Cytosorb™ system in a patient with legionella‐pneumonia associated rhabdomyolysis
Introduction:Rhabdomyolysis has been reported in the context of legionella pneumonia.1,2 Acute renal failure following rhabdomyolysis is a well known complication often indicating hemodialysis. Cytosorb™ was evaluated to reduce toxic levels of cytokines (in e.g. SIRS, sepsis, ARDS, trauma, burn injury) which lead to reduced clinical outcome following organ failure and immune suppression.3,4 Cytokines (10 ‐50 kDa) are adsorbed by polymer beads within the cartridge.3 The effectiveness of Cytosorb™ to remove myoglobin in vitro from saline solution and donated blood serum respectively has been demonstrated by V.Kuntsevich et al in 2009.5 So far in vivo data are missing.
(POTENTIAL) FIELDS OF APPLICATION / CYTOSORB TM
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE
CASE 272y‐old female patientcollapsed at home, immobility for about 6 hoursanuria, K+ incrase, myoglobin 200.000 ng/ml
CASE 367 y‐old male, burn injuryseverely damaged muscle mass despite escherichotomiadeveloped renal failure on day 2 after admission
(POTENTIAL) FIELDS OF APPLICATION / CYTOSORB TM
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE
CASE 272y‐old female patientcollapsed at home, immobility for about 6 hoursanuria, K+ incrase, myoglobin 200.000 ng/ml
stop of citrate dialysis on day 3adequate urine output (1ml/kg/h) from day 4 on
(support of furosemide 20 mg i.v. / 2x/d)
transfer to normal ward on day 9
… it seems if as if CytoSorb might be a therapeutic option in RRT due to rhabdomyolysis because of its excellent myoglobin binding properties……
UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE
ABOUT 25 PATIENTS TREATED SO FAR:
SEPSIS and severe SEPSIS
Severe Infection with RHABDOMYOLYSIS
Aortic Aneurysm with Escheriotomia – MYOGLOBINÄMIA
necrotizing FASCIITIS
PATIENTS SCREENED
severe acute Pancreatitis
Burn and severe Smoke Inhalation injury
Extracorporeal Circulation / CABG – ECMO
EASY TO USE ‐ NO COMPLICATIONS OBSERVED
DIE FOLGEN DES TRAUMAS – INFLAMMATION, SIRS und SEPSIS
(POTENTIAL) FIELDS OF APPLICATION / CYTOSORB TM
severe Sepsis and Septic shock
post‐operative SIRS
(e.g. after cardiopulmonary bypass)
intraoperative (e.g. HLM procedures > 2 hours)
ARDS Polytrauma
severe acute Pancreatitis
adverse Drug Reaction
Anaphylaxis
Rhabdomyolysis
Burn and Severe Smoke inhalation injury
CGK 2014
SUMMARY STRATEGIES TO IMPROVE OUTCOME –
ADJUVANT MEASURES
IMPLEMENTATION OF „BEST PRACTICE“ WITH REGARD
TO GUIDELINES AND EBM IN A COOPERATIVE TEAM APPROACH
CREATIVE AND INNOVATIVE TREATMENT OPTIONS
IN AN EDUCATIVE AND ACADEMIC ENVIRONMENT
2nd CENTRAL AND EASTERN EUROPEAN SEPSIS FORUM / BUDAPEST 2014
CGK 2013
CGK 2013
BETWEEN TOO EARLY AND TOO LATE
IS ONLY ONE INSTANT
THANK YOU FOR YOUR ATTENTION
FRANZ WERFEL1890 - 1945