IMMUNOADSORPTION (IA) AND ENDOCARDITIS IN END STAGE RENAL DISEASE (ESRD) PATIENTS

Patients with ESRD  who suffer from infective endocarditis are at high risk for developing a systemic hyperinflammatory state that could lead to septic shock. IA, by removing inflammatory mediators, could be used as a means of controlling the “inflammatory” process and stabilizing the patient’s clinical and hemodynamic picture.

We have 2 clinical examples of such case, which both of them were extremely challenging.  

First patient,   a 81-year-old female patient with ESRD  for 5 years was admitted to the hospital urgently due to high fever (39°C) for hours. That was a patient with many comorbidities (Type II diabetes, hypertension, atrial fibrillation, heart failure with polyvalvular disease, history of Chronic Myeloid Leukemia since 5 years), in whom during the paraclinical examination of her admission, a positive blood culture (s.aureus), a mobile mass on the ventral surface of the aortic valve and an intrapulmonary ventricular lesion in the right lower lobe of the lung were found. The patient's clinical picture remained severe for the first 24 hours with hemodynamic instability, fever and mental clouding. She was put on intravenous antibiotic treatment, the permanent central venous catheter was removed, a temporary one was placed and it was decided to undergo 2 consecutive IA  sessions with an HA330 filter simultaneously with the hemodialysis session.

Second patient, a 78 years old male  with ESRD for a year years was admitted to the hospital urgently due to spikes of  fever  for a week.  That was also a  patient with many comorbidities (Type II diabetes, hypertension, atrial fibrillation, heart failure with severe polyvalvular disease, bioprosthetic aortic valve).  He had also a recent history of prolonged hospitalizations due to restoration of abdominal aneurism with stent, soft tissue infections and hemorrhagic disposition.  His  positive blood culture (s.epidermis ) combined with  a mobile mass on the ventral surface of the mitral valve. Due to the fragile status  of the patient, he was under the care of ICU, with hemodynamic instability, fever and mental clouding. He was put on intravenous antibiotic treatment (changed twice) , the permanent central venous catheter was removed, a temporary one was placed. His clinical and laboratory  condition  went worse rapidly.  As a rescue  therapy it was decided to undergo 2 consecutive IA  sessions in 2 days with the filter IA  Efferon ( 4 hours per session). 

The first patient improved clinically and hemodynamically. The inflammatory markers (CRP, procalcitonin) significantly decreased. Although the prerequisites for surgical treatment of infective endocarditis were not present, the patient's clinical picture slowly and steadily improved and she was discharged after 33 days of hospitalization.

Second patient, despite the significant decrease of inflammatory markers (CRP-procalcitonin ) after sessions  of IA  finally did not manage to face effectively this severe septic shock and passed away. 

Our experience with IA and endocarditis gave us a lot of lessons.  Despite the fact that we were dealing with severe cases it seems that IA is a safe and well-tolerated option for the management of patients in an intense hyperinflammatory state. It should be emphasized that although the above clinical experience holds promise for new future therapeutic options, it is difficult to determine whether the effect ( or no) on the patients is due solely to IA (time, dose, duration, etc)  or to the combination of all therapeutic interventions. Randomized studies or at least more observational data are needed to reach more secure conclusions.  Surely new option of IA devices such as Efferon open the path to new horizons since it deals with endotoxins also.  It is also obvious that we need in the every day clinical practice  more targeted use of IA  therapy, and  for that reason  appropriate selection criteria are required.