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