PREVENTION OF RENAL FAILURE

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1 1 st 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

2 CONFLICT OF INTEREST CGK 2012

3 - STRATEGIES TO IMPROVE OUTCOME PATIENT IDENTIFICATION IDENTIFICATION & RISK STRATIFICATION despite SOPs, bundles and guidelines, treatment differs between individuals and centers CGK 2014

4 DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS BENCHMARK

5 1 st INTERNAT. CYTOSORB USER MEETING 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

6 1 st INTERNAT. CYTOSORB USER MEETING 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

7 INFLAMMATION, SIRS and SEPSIS CGK 2013

8 INFLAMMATION, SIRS and SEPSIS CGK 2013

9 ADJUVANT THERAPEUTIC OPTIONS DURING INFLAMMATION AND INFECTION Rimmelé T, Kellum JA, Anesthesiology Jun;116(6): REGAIN CONTROL ON THE xx CYTOKINE STORM WITH CYTOSORB TM Source Images: Valenti, I Characterization of a Novel Sorbent Polymer for the Treatment of Sepsis 2008 DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

10 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): DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

11 EFFECTS ON ORGAN DYSFUNCTION BY CYTOSORB TM KIDNEY Cytosorb Control LIVER Cytosorb 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): DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

12 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

13 SAFETY STUDIES DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

14 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: DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

15 UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE

16 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 So far in vivo data are missing. Figure 1: decrease of myoglobin levels during cytosorb application (1 st run: 0 6hours; 2 nd run: 9 14hours) DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS CGK 2013

17 DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS (POTENTIAL) FIELDS OF APPLICATION / CYTOSORB TM

18 UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE CASE 2 72y old female patient collapsed at home, immobility for about 6 hours anuria, K + incrase, myoglobin 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

19 DIAGNOSIS AND (ADJUVANT) THERAPY OF SEPSIS (POTENTIAL) FIELDS OF APPLICATION / CYTOSORB TM

20 UNIVERSITY VIENNA CYTOSORB TM EXPERIENCE CASE 2 72y old female patient collapsed at home, immobility for about 6 hours anuria, K + incrase, myoglobin 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

21 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

22 (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

23 2 nd 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

24 CGK 2013

25 BETWEEN TOO EARLY AND TOO LATE IS ONLY ONE INSTANT FRANZ WERFEL THANK YOU FOR YOUR ATTENTION CGK 2013

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