Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis

Abstract

Background: Rhabdomyolysis is frequently occurring in critically ill patients, resulting in a high risk of acute kidney injury (AKI) and potentially permanent kidney damage due to increased myoglobin levels. The extracorporeal elimination of myoglobin might be an approach to prevent AKI, but its molecular weight of 17 kDa complicates an elimination with conventional dialysis membranes. Question of interest is, if myoglobin can be successfully eliminated with the cytokine adsorber Cytosorb® (CS) integrated in a high-flux dialysis system.

Methods: Patients were included between 10/2014 and 05/2020 in the study population if they had an anuric renal failure with the need of renal replacement therapy, if CS therapy was longer than 90 min and if myoglobin level was > 5.000 ng/ml before treatment. The measurement times of the laboratory values were: d-1 = 24-36 h before CS, d0 = shortly before starting CS and d1 = 12-24 h after starting CS treatment. Statistical analysis were performed with Spearman's correlation coefficient, Wilcoxon test with associated samples and linear regression analysis.

Results: Forty-three patients were included in the evaluation (median age: 56 years, 77% male patients, 32.6% ECMO therapy, median SAPS II: 80 points and in-hospital mortality: 67%). There was a significant equilateral correlation between creatine kinase (CK) and myoglobin at all measurement points. Furthermore, there was a significant reduction of myoglobin (p = 0.03, 95% confidence interval (CI): - 9030, - 908 ng/ml) during CS treatment, with a median relative reduction of 29%. A higher median reduction of 38% was seen in patients without ongoing rhabdomyolysis (CK decreased during CS treatment, n = 21). In contrast, myoglobin levels did not relevantly change in patients with increasing CK and therefore ongoing rhabdomyolysis (n = 22, median relative reduction 4%). Moreover, there was no significant difference in myoglobin elimination in patients with and without ECMO therapy.

Conclusion: Blood purification with Cytosorb® during high-flux dialysis led to a significant reduction of myoglobin in patients with severe rhabdomyolysis. The effect might be obscured by sustained rhabdomyolysis, which was seen in patients with rising CK during treatment. Prospective clinical trials would be useful in investigating its benefits in avoiding permanent kidney damage.

Keywords: Acute kidney injury; Blood purification; Cytosorb ®; Myoglobin; Rhabdomyolysis.

Fig. 1

CK and myoglobin values of all patients at different time points. Myo Myoglobin, CK creatine kinase, d-1 24–36 h before Cytosorb® treatment, d0 0–12 h before CS treatment, d1 12–24 h after beginning Cytosorb® treatment, orange line represents the median, gray boxes the interquartile range and the whiskers are limited to 1.5 times the interquartile range

Fig. 2

Relative change (%) of myoglobin and CK during CS treatment. CK creatine kinase, CS Cytosorb®, green dots: decrease of CK during CS treatment (= group 1), red dots: increase of CK during CS treatment (= group 2)

Fig. 3

Median CK and myoglobin levels in the different groups. CK creatine kinase, Myo myoglobin, − 1: day − 1, 0: day 0, 1: day 1, green beams: decrease of CK during CS treatment (= group 1), red beams: increase of CK during CS treatment (= group 2)