Case of the Week
Use of CytoSorb in a patient with acute renal failure and hyperbilirubinemia
Dr. Katarina Foraboschi | Anesthesiology and Intensive Care Medicine, Ordensklinikum Linz GmbH, Linz, Austria
05/18/2022
New!Other indicationsReduction in catecholaminesSafetyAnticoagulation OthersBilirubinCase of the weekCase reportCRRT pre filterImprov. hep. encephalopathyInflammatory parametersLiver failure
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Summary
CoW 20/2022 – This case reports on a 53-year-old male patient who was transferred from a peripheral hospital to Ordensklinikum Linz with initial manifestation of Hodgkin’s disease (stage IV/B/E, lymph nodes neck, bulks retroperitoneal, diffuse liver involvement, bone marrow involvement) as well as acute renal failure requiring hemodialysis.
Case presentation
Medical history also included type II diabetes mellitus, chronic bronchial asthma, arterial hypertension and hepatosplenomegaly
On admission, the patient had an American Society of Anesthesiologists (ASA) classification score of 3 and a Glasgow Coma Scale (GCS) score of 15
Additionally, he exhibited accompanying thrombocytopenia, pancytopenia as well as suspected atypical hemolytic syndrome
Initially, the patient was respiratory and hemodynamically stable. Catheterization was performed for volume balancing and optimization. In addition, the patient received albumin, insulin lispro in the context of his pre-existing diabetes mellitus II and a total of 2 red cell concentrates due to evident pancytopenia
On the following day, the patient was admitted to the intensive care unit following a deterioration in renal and liver parameters
The first dose of chemotherapy had no hemodynamic effects
One day later, however, the patient developed full-blown multi-organ failure including oliguric/anuric renal failure and liver failure with bilirubin levels up to (20 mg/dl) and incipient hepatic encephalopathy
Furthermore, the patient developed severe hemodynamic instability requiring initiation of norepinephrine up to 0.2 µg/kg/min
In addition, he was in a hyperinflammatory condition with elevated C-reactive protein (CRP) levels (25 mg/dl)
In the evening of the same day, continuous renal replacement therapy (CRRT) was started due to ongoing increases in his retention parameters with a simultaneous adjustment of antibiotic therapy with meropenem to 3x 2g
With the rationale of reducing the excessive bilirubin plasma levels, a CytoSorb hemoadsorber was additionally integrated into the CRRT circuit
The patient was breathing spontaneously throughout his course and only required intermittent respiratory support via nasal cannula (low-flow)
Treatment
Two treatments with CytoSorb were performed (1st treatment for 3 hours, 2nd treatment for 8 hours). The first adsorber had to be changed prematurely due to system clotting. Following the application of enoxaparin, the 2nd treatment session could be run without any problems
CytoSorb was performed in combination with CRRT (Multifiltrate Pro, Fresenius) run in hemodiafiltration mode (CVVHDF)
Blood flow rate: 250 ml/min
Anticoagulation: initially none, due to derailed plasma coagulation, following systemic clotting then anticoagulation with enoxaparin 40 mg systemically
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and norepinephrine dose
Inflammatory markers
Bilirubin levels
Renal function
Overall clinical condition
Results
Supportive hemodynamic therapy with norepinephrine could be significantly reduced on the first day and finally completely stopped after a total of 4 days
During treatment, CRP levels dropped to 16 mg/dl and subsequently continued to decrease to normal levels
CytoSorb treatment was also associated with a significant reduction in plasma bilirubin levels (down to 8 mg/dl after completion of CytoSorb treatment and a further spontaneous reduction thereafter)
Under combined standard CRRT and CytoSorb therapy, renal function continued to stabilize, and spontaneous diuresis resumed (1400 ml within 12 hours)
The patient’s clinical condition including the hepatic encephalopathy also improved rapidly under ongoing therapy
Patient Follow-Up
Discontinuation of CRRT after a total of 12 hours together with CytoSorb with significantly improved diuresis over the following days
At the time of documentation, the patient was still on chemotherapy, currently on a curative approach
At the time of transfer, the patient was cooperative, hemodynamically and respiratory stable
Conclusion
In this case of a patient with acute renal failure and hyperbilirubinemia, the use of CytoSorb in combination with other therapeutic measures including CRRT led to a significant and steady improvement of the critical situation, particularly due to the rapid stabilization in hemodynamics, a rapid and sustained reduction in bilirubin levels, and an improvement in renal function and his overall clinical condition
The primary goal of reducing hyperbilirubinemia and improving hepatic encephalopathy was rapidly achieved, without complications, and in a patient-safe manner.The clinical and laboratory improvement enabled a more rapid administration of chemotherapeutic agents, which, presumably, in combination with causal therapy, improved the patient’s final outcome
CytoSorb was easy and safe to use in this setting.
