PREVENTION OF RENAL FAILURE – DUE TO

1st INTERNAT. CYTOSORB USER MEETING 2015
PREVENTION OF RENAL FAILURE –
DUE TO RHABDOMYOLYSIS xxx
A CASE REPORT USING CYTOSORB xi
CLAUS-GEORG KRENN / 16. III. 2015
CONFLICT OF INTEREST
CGK 2012
- STRATEGIES TO IMPROVE OUTCOME –
PATIENT IDENTIFICATION
IDENTIFICATION
&
RISK STRATIFICATION
… despite SOPs, bundles and guidelines, treatment differs between individuals and centers … CGK 2014
BENCHMARK
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
1st INTERNAT. CYTOSORB USER MEETING 2015

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
CGK 2013
1st INTERNAT. CYTOSORB USER MEETING 2015


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 THERAPY
Ronco C., Crit Care 2005: 9:141
Brochard L., Am J Resp Crit Care Med 2010; 181: 1128
Petejova N., Crit Care 2014; 18:224
CGK 2013
INFLAMMATION, SIRS and SEPSIS
CGK 2013
INFLAMMATION, SIRS and SEPSIS
CGK 2013
ADJUVANT THERAPEUTIC OPTIONS DURING INFLAMMATION AND INFECTION
REGAIN CONTROL ON THE xx
CYTOKINE STORM WITH CYTOSORB
TM
Rimmelé T, Kellum JA, Anesthesiology. 2012 Jun;116(6):1377-87
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
Creatinine (marker of kidney dysfunction)
HMGB‐1
(protein indicative for cell injury)
ALT (protein indicative for liver cell injury)
CytoSorb™‐reduces organ injury as shown by the decreased release of:
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.
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
CGK 2013
EFFECTS ON ORGAN DYSFUNCTION
BY
KIDNEY
Cytosorb
LIVER
Cytosorb
CYTOSORB TM
Control
Control
Development of severe kidney and liver tissue injury could be attenuated in the CytoSorb™‐treated group
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.
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
CGK 2013
SAFETY STUDIES

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
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
CGK 2013
SAFETY STUDIES
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
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
CGK 2013
UNIVERSITY VIENNA CYTOSORBTM EXPERIENCE
CASE REPORT / CYTOSORB TM
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.
Figure 1:
decrease of myoglobin levels during cytosorb™ application (1st run: 0‐6hours; 2nd run: 9‐14hours)
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
CGK 2013
(POTENTIAL) FIELDS
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
OF
APPLICATION / CYTOSORB TM
UNIVERSITY VIENNA CYTOSORB
TM
EXPERIENCE
CASE 2
72y‐old female patient
collapsed at home, immobility for about 6 hours
anuria, K+ incrase, myoglobin 200.000 ng/ml
CASE 3
67 y‐old male, burn injury
severely damaged muscle mass despite escherichotomia
developed renal failure on day 2 after admission
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
(POTENTIAL) FIELDS
DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
OF
APPLICATION / CYTOSORB TM
UNIVERSITY VIENNA CYTOSORB
TM
EXPERIENCE
CASE 2
72y‐old female patient
collapsed at home, immobility for about 6 hours
anuria, K+ incrase, myoglobin 200.000 ng/ml
stop of citrate dialysis on day 3
adequate 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…… DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS
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
(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
DIE FOLGEN DES TRAUMAS – INFLAMMATION, SIRS und SEPSIS
2nd CENTRAL
AND
EASTERN EUROPEAN SEPSIS FORUM / BUDAPEST 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
CGK 2014
CGK 2013
BETWEEN TOO EARLY AND TOO LATE
IS ONLY ONE INSTANT
FRANZ WERFEL
1890 - 1945
THANK YOU FOR YOUR ATTENTION
CGK 2013