ESPN 50th Annual Meeting

ESPN 2017


 
MULTI ORGAN FAILURE WITH SEVERE RHABDOMYOLYIS AFTER CARDIAC TRANSPLANT SUCCESSFULLY TREATED WITH CRRT WITH AN69 HEPARIN ENGRAFTED FILTER OXIRIS
ENRICO COCCHI 1 ROBERTO BONAUDO 1 FRANCESCA MATTOZZI 1 ALBERTA RIZZO 2 CARLO PACE NAPOLEONE 3 BRUNO GIANOGLIO 1 LICIA PERUZZI 1

1- NEPHROLOGY AND DIALYSIS UNIT REGINA MARGHERITA CHILDRENS HOSPITAL TURIN ITALY
2- CARDIAC SURGERY INTENSIVE CARE R. MARGEHERITA CHILDRENS HOSPITAL
3- CARDIAC SURGERY REGINA MARGHERITA CHILDRENS HOSPITAL
 
Introduction:

Severe low cardiac output after cardiac surgery may often cause multiorgan ischemic failure (MOF) with rhabdomyolysis, inflammatory response and acute kidney injury increasing dramatically mortality rate.

Here we present a case of AKI due to MOF with severe rhabdomyolysis after low cardiac output occurring after heart transplantation in a 14 years-old patient completely recovered with a super high flux CVVHDF with oXiris® filter (Gambro, Sweden) (AN69 permanently heparin grafted designed for specific adsorption of endotoxin and cytokines).  

Material and methods:

A 14 years-old male born with Hypoplastic Right Heart Syndrome treated with Norwood, bidirectional Glenn, Fontan intervention, aortic, cavo-pulmonary connection, multiple caval angioplasty and stent placements during the first 10 years of life, developed progressive worsening of the right cardiac function until protein wasting entheropathy. Variously treated until high-protein parenteral nutrition.

In december 2016 he received heart transplantation requiring 100% ECMO placement on day 1. Since day 2 he developed progressive oligo-anuria unresponsive to diuretics (10 mg/kg furosemide and 0.5 mg/kg etacrynic acid) and severe hyperkalemia.

Results:

CVVHDF was started while on ECMO through a left femoral vein double-lumen catheter (11 F, 15 cm) at Qb=180 ml/min, Qd=5000 ml/h and 1000 ml/h prediluition using Prismaflex machine equipped with ST150 filter.

On day 3 Creatine Kinase (CK) and free myoglobin (Myo) dramatically increased showing severe rhabdomyolysis (CK from 1030 UI/L day 1, 150100 UI/L day 2, to 429000 UI/L day 3; Myo from 5000 ng/ml to 18000 ng/ml). The oXiris AN69 filter was maintained for 96 hours. We observed a rapid decline of CK to 88600 UI/L and Myoglobin to 13725, 14865, 8063 at 24, 48, 72 and 96hrs  respectively and a rapid improvement of hemodynamic stability.

The rapid clearance of rhabdomylolysis and inflammatory cascade products allowed a prompt improvement of the cardiac function and exit from ECMO after 5 days.

CVVHDF progressively tapered and stopped after 28 days when diuresis and serum creatinine normalized.

Conclusions:

This positive experience with this AN69 heparin grafted filter designed to adsorb cytokines, endotoxin and possibly myoglobin shoud be taken into consideration for severe multiorgan failures with AKI with rhabdomyolysis or septic shock also in children.