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Therapeutic Apheresis and Dialysis 2014; 18(5):515–521 doi: 10.1111/1744-9987.12183,12165,12200,12269 © 2014 The Author Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Letters to the Editor
Continuous Renal Replacement Therapy in a Patient With Pulmonary Embolism Receiving Extracorporeal Membrane Oxygenation
to maintain hemodynamic stability, multiple units of blood products transfusion (packed red blood cells, platelets, cryoprecipitate and fresh frozen plasma) and medications to maintain sedation. This resulted in infusion of a massive amount of fluids (200– 400 mL/h). In the background of right heart dysfunction and anuria he required initiation of CRRT for maintenance of fluid balance and correction of electrolyte imbalance. The modality of CRRT used was continuous veno-venous hemofiltration and it was incorporated into the ECMO circuit. ECMO was discontinued after 3 days but CRRT had to be continued for another 2 weeks. Eventually he was switched to intermittent hemodialysis (IHD) with establishment of hemodynamic stability. He continued on IHD for another 4 weeks and was weaned off dialysis. One year after the event, his creatinine is stable around 123.76–141.4 μmol/L (normal: 53.04–97.24 μmol/L)
Dear Editor, Massive pulmonary embolism (PE) is a life threatening condition with high morbidity and mortality (1). We discuss the clinical features and outcome of a patient with massive PE who was treated with extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). A similar case has not been reported in the literature before. A 44-year-old Caucasian male with no significant past medical history presented to the emergency department with a one-day history of shortness of breath and generalized weakness. There was no history of lower extremity swelling, cough, chest pain or fever. Family history was significant only for deep vein thrombosis (DVT) in his grandmother. Physical exam was remarkable for tachycardia, hypotension and jugular venous distension. Pertinent admission laboratory tests included bicarbonate 14 mmol/L (normal: 20–29 mmol/ L), urea nitrogen 11.42 mmol/L (normal: 2.49– 7.14 mmol/L), creatinine 167.9 μmol/L (normal: 53.04–97.24 μmol/L), lactate > 20 mmol/L (normal: 0.5–2.2 mmol/L), troponin 0.21 μg/L (normal: 0.00– 0.02 μg/L) and d-dimer > 20 000 μg/L (normal < 500 μg/L). A blood gas showed pH of 7.28 and pCO2 of 28 mmHg. Electrocardiogram showed sinus tachycardia, right ventricular strain pattern (S1, Q3, T3 and T-wave inversion in anterior leads). A bed-side echo showed enlarged right ventricle and elevated right ventricular systolic pressure (more than 90 mmHg). Pulmonary embolism was suspected and the patient was started on thrombolytic therapy with tissue plasminogen activator. Subsequently he was taken for surgery and intra-operatively a large saddle embolus was found in the main pulmonary artery for which embolectomy was performed. Following the surgery he had to be placed on ECMO through a veno-arterial circuit because of persistent hypoxia. Meanwhile he required four vasopressors
DISCUSSION Extracorporeal membrane oxygenation is widely used for the treatment of patients with PE associated with circulatory collapse and hypoxia resistant to conventional ventilator management (1). It has been found to improve survival in these patients (2). While on ECMO these patients receive large amounts of parenteral fluids in the form of blood products, medications and vasopressors. This will place an additional burden on the already failed right heart. Moreover, fluid overload has been found to have independent association with mortality (3). The use of CRRT will help in unloading the heart, which will subsequently result in improved left ventricular return, oxygenation of blood and oxygenation of tissues. This in turn can have benefits on the survival of these patients (4). Bijin Thajudeen Nephrology, University of Arizona, Tucson, AZ, USA Email: [email protected] REFERENCES 1. Munakata R, Yamamoto T, Hosokawa Y et al. Massive pulmonary embolism requiring extracorporeal life support treated with catheter-based interventions. Int Heart J 2012;53:370–4.
515
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516
Letters to the Editor
2. Ko CH, Forrest P, D’Souza R, Qasabian R. Successful use of extracorporeal membrane oxygenation in a patient with combined pulmonary and systemic embolisation. Perfusion 2013;28:138–40. 3. Bouchard J, Soroko SB, Chertow GM et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009;76:422–7. 4. Mirhosseini SM, Fakhri M, Asadollahi S et al. Continuous renal replacement therapy versus furosemide for management of kidney impairment in heart transplant recipients with volume overload. Interact Cardiovasc Thorac Surg 2013;16:314–20.
Successful Treatment of Enterohemorrhagic Escherichia coli O111-Induced Acute Encephalopathy and Hemolytic-Uremic Syndrome With Plasma Diafiltration Dear Editor, A 7-year-old girl was referred to us with a 2-day history of abdominal pain and bloody stools. Enterohemorrhagic Escherichia coli (EHEC) O111 producing shiga toxin (STx)-1 and 2 was detected in the stool culture. She became lethargic on day 3 of hospitalization. Laboratory examinations revealed thrombocytopenia, hemolytic anemia and acute renal failure. On day 5 of hospitalization, she experienced alterations in her consciousness level with abnormal findings of magnetic resonance image. These findings indicated the diagnosis of EHEC O111-associated hemolytic uremic syndrome (HUS) with acute encephalopathy. Treatment with continuous hemodiafiltration (CHDF) was initiated, but her disease condition did not improve (Fig. 1A). The levels of serum IL-6 increased after CHDF therapy (before 440 pg/mL, after 740 pg/mL; normal
Therapeutic Apheresis and Dialysis 2014; 18(5):515–521 doi: 10.1111/1744-9987.12183,12165,12200,12269 © 2014 The Author Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Letters to the Editor
Continuous Renal Replacement Therapy in a Patient With Pulmonary Embolism Receiving Extracorporeal Membrane Oxygenation
to maintain hemodynamic stability, multiple units of blood products transfusion (packed red blood cells, platelets, cryoprecipitate and fresh frozen plasma) and medications to maintain sedation. This resulted in infusion of a massive amount of fluids (200– 400 mL/h). In the background of right heart dysfunction and anuria he required initiation of CRRT for maintenance of fluid balance and correction of electrolyte imbalance. The modality of CRRT used was continuous veno-venous hemofiltration and it was incorporated into the ECMO circuit. ECMO was discontinued after 3 days but CRRT had to be continued for another 2 weeks. Eventually he was switched to intermittent hemodialysis (IHD) with establishment of hemodynamic stability. He continued on IHD for another 4 weeks and was weaned off dialysis. One year after the event, his creatinine is stable around 123.76–141.4 μmol/L (normal: 53.04–97.24 μmol/L)
Dear Editor, Massive pulmonary embolism (PE) is a life threatening condition with high morbidity and mortality (1). We discuss the clinical features and outcome of a patient with massive PE who was treated with extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). A similar case has not been reported in the literature before. A 44-year-old Caucasian male with no significant past medical history presented to the emergency department with a one-day history of shortness of breath and generalized weakness. There was no history of lower extremity swelling, cough, chest pain or fever. Family history was significant only for deep vein thrombosis (DVT) in his grandmother. Physical exam was remarkable for tachycardia, hypotension and jugular venous distension. Pertinent admission laboratory tests included bicarbonate 14 mmol/L (normal: 20–29 mmol/ L), urea nitrogen 11.42 mmol/L (normal: 2.49– 7.14 mmol/L), creatinine 167.9 μmol/L (normal: 53.04–97.24 μmol/L), lactate > 20 mmol/L (normal: 0.5–2.2 mmol/L), troponin 0.21 μg/L (normal: 0.00– 0.02 μg/L) and d-dimer > 20 000 μg/L (normal < 500 μg/L). A blood gas showed pH of 7.28 and pCO2 of 28 mmHg. Electrocardiogram showed sinus tachycardia, right ventricular strain pattern (S1, Q3, T3 and T-wave inversion in anterior leads). A bed-side echo showed enlarged right ventricle and elevated right ventricular systolic pressure (more than 90 mmHg). Pulmonary embolism was suspected and the patient was started on thrombolytic therapy with tissue plasminogen activator. Subsequently he was taken for surgery and intra-operatively a large saddle embolus was found in the main pulmonary artery for which embolectomy was performed. Following the surgery he had to be placed on ECMO through a veno-arterial circuit because of persistent hypoxia. Meanwhile he required four vasopressors
DISCUSSION Extracorporeal membrane oxygenation is widely used for the treatment of patients with PE associated with circulatory collapse and hypoxia resistant to conventional ventilator management (1). It has been found to improve survival in these patients (2). While on ECMO these patients receive large amounts of parenteral fluids in the form of blood products, medications and vasopressors. This will place an additional burden on the already failed right heart. Moreover, fluid overload has been found to have independent association with mortality (3). The use of CRRT will help in unloading the heart, which will subsequently result in improved left ventricular return, oxygenation of blood and oxygenation of tissues. This in turn can have benefits on the survival of these patients (4). Bijin Thajudeen Nephrology, University of Arizona, Tucson, AZ, USA Email: [email protected] REFERENCES 1. Munakata R, Yamamoto T, Hosokawa Y et al. Massive pulmonary embolism requiring extracorporeal life support treated with catheter-based interventions. Int Heart J 2012;53:370–4.
515
bs_bs_banner
516
Letters to the Editor
2. Ko CH, Forrest P, D’Souza R, Qasabian R. Successful use of extracorporeal membrane oxygenation in a patient with combined pulmonary and systemic embolisation. Perfusion 2013;28:138–40. 3. Bouchard J, Soroko SB, Chertow GM et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009;76:422–7. 4. Mirhosseini SM, Fakhri M, Asadollahi S et al. Continuous renal replacement therapy versus furosemide for management of kidney impairment in heart transplant recipients with volume overload. Interact Cardiovasc Thorac Surg 2013;16:314–20.
Successful Treatment of Enterohemorrhagic Escherichia coli O111-Induced Acute Encephalopathy and Hemolytic-Uremic Syndrome With Plasma Diafiltration Dear Editor, A 7-year-old girl was referred to us with a 2-day history of abdominal pain and bloody stools. Enterohemorrhagic Escherichia coli (EHEC) O111 producing shiga toxin (STx)-1 and 2 was detected in the stool culture. She became lethargic on day 3 of hospitalization. Laboratory examinations revealed thrombocytopenia, hemolytic anemia and acute renal failure. On day 5 of hospitalization, she experienced alterations in her consciousness level with abnormal findings of magnetic resonance image. These findings indicated the diagnosis of EHEC O111-associated hemolytic uremic syndrome (HUS) with acute encephalopathy. Treatment with continuous hemodiafiltration (CHDF) was initiated, but her disease condition did not improve (Fig. 1A). The levels of serum IL-6 increased after CHDF therapy (before 440 pg/mL, after 740 pg/mL; normal
