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Rapid reduction of substantially increased myoglobin and creatine kinase levels using a hemoadsorption device (CytoSorb®) – A case report
Erich Moresco, Christopher Rugg, Mathias Ströhle, Matthias Thoma | Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria | Clin Case Rep. 2022;10:e05272.
04/13/2022
New!Peer Reviewed Published DataRhabdomyolysisTraumaImpact on organ supportCase of the weekCase reportCritical CareCRRT (pre or post filter)
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Summary
CoW 15/2022 – This case reports on a 24-year-old, initially healthy male patient, who suffered a knee dislocation due to a sports trauma.
Summary
In this case report a previously healthy 24 yr old had surgery in a peripheral hospital after dislocating his knee whilst playing sports. During the five hour surgery he had a tourniquet applied to his thigh for 2 hours. The next day he developed brown colored urine and was found to have already impaired kidney function (estimated glomerular filtration rate [eGFR] 50 ml/min/1.73m, serum creatinine [SC] 1.68 mg/dl, creatinine kinase [CK] 89,968 U/l, myoglobin >500 µg/l) so a diagnosis of rhabdomyolysis was made. The patient was transferred to a central hospital for fasciotomy and hematoma evacuation and admitted to the intensive care care (ICU) post operatively. On ICU admission myoglobin was 15,993 µg/l and CK 79,182 U/l. Continuous veno-venous hemofiltration (CVVHF) with an AN69 ST membrane was then started purely so that the patient could be treated with a CytoSorb adsorber. Within 24 hrs of treatment CK levels had reduced by more than 50% (34,630 U/l) and myoglobin by more than 80% (3730 µg/l). Prior to hospital discharge on day 15 he had a fully recovered renal function. In summary, the immediate use of CRRT with the addition of CytoSorb led to the highly efficient reduction in CK and myoglobin concentrations from the blood. The authors speculate that in the future this might justify implementation of CRRT as well as a hemoadsorber such as CytoSorb, as soon as excessive myoglobin peak levels are reached and the cause for this is known. The early use of CRRT with the addition of the adsorber could help to prevent acute kidney injury (AKI) instead of just treating the AKI typically caused by this clinical scenario afterwards.
Case presentation
Surgery was performed with a combined general anesthesia and peripheral nerve block (preoperative blood analysis was as follows: creatine kinase (CK) levels 1300 U/l, estimated glomerular filtration rate (eGFR) 82 ml/min/1.73m², serum creatinine (SC) 1.1 mg/dl
The procedure was performed in a peripheral clinic, lasted 5 hrs, and included the use of a tourniquet around the thigh for approximately 2 hours
The following day after surgery, the patient developed a swollen thigh and brown-colored urine
Laboratory results showed elevated levels of CK (89,968 U/l) and myoglobin (>500 µg/l, unspecified) with an already impaired kidney function (eGFR 50 ml/min/1.73m², SC 1.68 mg/dl)
The patient was promptly transferred to the authors hospital for surgical fasciotomy and hematoma evacuation
Postoperatively, the patient was admitted to the Intensive CareUnit (ICU) for further care
On ICU admission myoglobin and CK levels were 15,993 µg/l and 76,182 U/l, respectively
Continuous renal replacement therapy (CRRT) was promptly initiated, carrying a CytoSorb adsorber column, with no other indications than carrying CytoSorb necessitated the start of CRRT
Treatment
One treatment with CytoSorb was performed for 24 hours
CytoSorb was used in combination with CRRT (Gambro Prismaflex Baxter, Deerfield, USA) run in continuous veno-venous hemofiltration (CVVHF) mode using a AN-69 ST membrane as a hemofilter
Blood ?ow rate: 150 ml/min
Resulting pre-dilution fluid: 1500 ml/hour
Post-dilution fluid: 1000 ml/hour
Withdrawal/ultrafiltration: 100 ml/hour
Anticoagulation: Trisodium citrate
Measurements
Myoglobin and CK plasma levels
eGFR
Results
Within 24 hours, a reduction in CK levels by more than 50% and myoglobin levels by more than 80% was achieved
The eGFR improved from 41 to 61 ml/min/1.73m² throughout the combined CRRT/CytoSorb treatment session
Patient Follow-up
Osmodiuretics (mannitol 15%) were administered intravenously on the first 2 days in ICU (total amount: 500 ml). Additional bicarbonate was not given. Resuscitation fluid therapy was conducted with colloids (Gelofusine® 4%, B. Braun, Melsungen, Germany). Maintenance fluids included balanced crystalloids (ELO-MEL isotone Fresenius Kabi, Bad Homburg, Germany)
CRRT therapy was continued up to the 6th postoperative day and was then stopped
He was eventually transferred to the intermediate care on the 7th day and discharged from hospital on the 16thpostoperative day
The day before hospital discharge laboratory results showed a fully recovered renal function (eGFR 122 ml/min/m², SC 0.78 mg/dl) and normal levels of creatine kinase (161 U/l) and myoglobin (28 µg/l)
Conclusion
In summary, the immediate use of CRRT with the addition of CytoSorb led to the highly efficient reduction in CK and myoglobin concentrations from the blood
The authors speculate that in the future this might justify implementation of CRRT as well as CytoSorb, as soon as excessive myoglobin peak levels are reached and the cause for this is known
The early use of CRRT with the addition of the adsorber could help to prevent acute kidney injury (AKI) instead of just treating the AKI typically caused by this clinical scenario afterwards.
