EARLY HEMOFILTRATION THERAPY IN A PATIENT WITH SEVERE RHABDOMYOLYSIS WITH MULTIORGAN DYSFUNCTION SECONDARY TO CRUSH SYNDROME WITH RENAL FUNCTION RECOVERY. A CASE REPORT.

EARLY HEMOFILTRATION THERAPY IN A PATIENT WITH SEVERE RHABDOMYOLYSIS WITH MULTIORGAN DYSFUNCTION SECONDARY TO CRUSH SYNDROME WITH RENAL FUNCTION RECOVERY. A CASE REPORT.

Acute kidney injury (AKI) is one of the most severe complications of rhabdomyolysis (RM) and the prognosis is worse when the main cause is related to trauma.  RM is a clinical syndrome characterized by injury to skeletal muscle fibers with disruption and released of their contents into de circulation  such as myoglobin, creatine phosphokinase (CK) and lactate dehydrogenase as biomarkers of muscle damage.  Extracorporeal techniques can be ineffective removing myoglobin, however the use of a membrane with super-high-flow continuous venovenous hemofiltration (CVVHF) have shown promising results in the treatment of acute RM. We aim to show our experience of early extracorporeal hemofiltration therapy in the management of severe RM induced AKI in a patient with multiorgan dysfunction secondary to crush syndrome.

We present the case of a 31 – year- old male with no medical history of kidney disease, who suffers multiple trauma secondary to crushing due to a work accident in a coal mine. Blood work at the admission showed the following: Creatinine: 4.1 mg/dl, Ureic Nitrogen (bun) 44.3 mg/dl, potassium 9.14 mEq/L, CK 221.731 U/L, arterial blood gas analysis showed metabolic acidosis: pH 7.18, serum bicarbonate 8 mEq/L, and partial pressure of carbon dioxide 21.7 mmHg with persistent anuria. CVVHF was started in the first hour following the trauma and hospital admission. CVVHF parameters were:  ST Filter 150 with membrane type  AN69 , pump flow (QB) 150-200 ml/min with a pre filter effluent dose 100%  applying a dose of  60 cc kg hour for 6 hours under intention of CVVHF pulse formulation with continuity then at dose of 35 cc kg in CVVHF, without anticoagulation, only washing with saline solution 0,9% 200 cc each hour and with restitution solution in predilution with prixmasate bgk 4/2,5. The previous cycle was repeated for 72 hours.

The patient was admitted to the ICU and daily review of laboratory tests was performed. After 36 hours of the initiation of the CCVHF levels of CK decrease significantly from 221.731 U/L to 108.000 U/L, with normalization of potassium levels as well with 4.7 mEq/L. Completing the 72 hours of CCVHF the levels of CK were 5.578 U/L, however hyperkalemia and hyperazoemia persisted Creatinine: 4.36 mg/dl, bun 68 mg/dl, potassium 5.8 mEq/L so conventional hemodialysis was prescribed.  It is worth clarify that in our center we do not have myoglobin testing so the effectiveness of the therapy was measured by the decrease in CK serum levels. Nevertheless creatinine levels before medical discharge were 4.43 mg/dl therefore it was indicated to continue renal replacement therapy on an outpatient basis; nonetheless one week after hospital discharge, in the ambulatory renal unit recovery of renal function happens and a significant decrease in CK was documented Creatinine: 1.52 mg/dl CK: 398 U/L , so it was decided to withdraw hemodialysis therapy.

The use of hyperpermeable membranes in CCVHF at early time could represent an effective approach to the treatment of AKI  induced by RM with a fast and efficient decreased of CK serum levels as an indirect measurement of myoglobin depuration even in cases where CK is critically elevated, thus generating successful kidney recovery with no mortality in our experience.

No conflict of interest.