Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force

Lui Forni^{1

2}, Filippo Aucella³, Gabriella Bottari⁴, Stefan Büttner⁵, Vincenzo Cantaluppi^{6

7}, Dietmar Fries⁸, Jan Kielstein⁹, Detlef Kindgen-Milles¹⁰, Claus Krenn¹¹, Andreas Kribben¹², Andreas Meiser¹³, Steffen Mitzner¹⁴, Marlies Ostermann¹⁵, Vedran Premuzic¹⁶, Caroline Rolfes¹⁷, Christina Scharf¹⁸, Stefan Schunk¹⁹, Zsolt Molnar^{20

21

22}, Alexander Zarbock²³

Affiliations

¹ Critical Care Unit, Royal Surrey Hospital, Guildford, Surrey, UK. luiforni@nhs.net.
² School of Medicine, University of Surrey, Kate Granger Building, Guildford, UK. luiforni@nhs.net.
³ "Casa Sollievo della Sofferenza" Foundation, Scientific Institut for Research and Health Care, Viale Cappuccini, 1, San Giovanni Rotondo (FG), 71013, Italy.
⁴ Pediatric Intensive Care Unit, Bambino Gesu Children's Hospital, IRCCS, Rome, 00165, Italy.
⁵ Cardiology, Pulmonology, Nephrology and Intensive Care Medicine, Klinikum Aschaffenburg- Alzenau, Academic Teaching Hospital of Julius-Maximilians-University Würzburg, Aschaffenburg, Germany.
⁶ Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy.
⁷ "Maggiore della Carità" University Hospital, via Gen. P. Solaroli 17, Novara, 28100, Italy.
⁸ Department for Anaesthesia and Critical Care Medicine, Medical University, Christoph-Probst- Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, Innsbruck, 6020, Austria.
⁹ Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Naumburgstraße 15, D-38124, Braunschweig, Germany.
¹⁰ Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University, Moorenstr.5, D-40225, Duesseldorf, Germany.
¹¹ Clinic for Anaesthesia, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Wahringer Gurtel 18-20, Vienna, 1090, Austria.
¹² Universitätsklinikum Essen (AöR) Nephrology Clinic, Medizinisches Zentrum, 2.104 Hufelandstraße 55, D-45147, Essen, Germany.
¹³ Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Saarland University Hospital, D-66424, Homburg, Germany.
¹⁴ Fraunhofer IZI Rostock, Schillingallee 68, 18057, Rostock, Germany.
¹⁵ Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, London, SE1 9RT, UK.
¹⁶ Department for Nephrology, Hypertension, Dialysis and Transplantation, School of Medicine, UHC Zagreb Croatia, University of Zagreb, Šalata ul. 2, Zagreb, 10000, Croatia.
¹⁷ Department for Anesthesiology, Intensive Care Medicine, Pain Therapy and Emergency Medicine, GNH Klinikum Kassel, Mönchebergstraße 41-43, D-34125, Kassel, Germany.
¹⁸ Department of Anesthesiology, LMU University Hospital, LMU Munich, Geschwister-Scholl- Platz 1, D-80539, München, Germany.
¹⁹ Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Kirrberger Str. 100, D-66421, Homburg/Saar, Germany.
²⁰ Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, H-1082, Hungary.
²¹ Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Collegium Maius, Fredry 10, Poznan, 61-701, Poland.
²² CytoSorbents Europe, Müggelseedamm 131, D-12587, Berlin, Germany.
²³ Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany.

PMID: 39085790
PMCID: PMC11293130
DOI: 10.1186/s12882-024-03679-8

Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force

Lui Forni et al. BMC Nephrol. 2024.

. 2024 Jul 31;25(1):247.

doi: 10.1186/s12882-024-03679-8.

Authors

Affiliations

¹ Critical Care Unit, Royal Surrey Hospital, Guildford, Surrey, UK. luiforni@nhs.net.
² School of Medicine, University of Surrey, Kate Granger Building, Guildford, UK. luiforni@nhs.net.
³ "Casa Sollievo della Sofferenza" Foundation, Scientific Institut for Research and Health Care, Viale Cappuccini, 1, San Giovanni Rotondo (FG), 71013, Italy.
⁴ Pediatric Intensive Care Unit, Bambino Gesu Children's Hospital, IRCCS, Rome, 00165, Italy.
⁵ Cardiology, Pulmonology, Nephrology and Intensive Care Medicine, Klinikum Aschaffenburg- Alzenau, Academic Teaching Hospital of Julius-Maximilians-University Würzburg, Aschaffenburg, Germany.
⁶ Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy.
⁷ "Maggiore della Carità" University Hospital, via Gen. P. Solaroli 17, Novara, 28100, Italy.
⁸ Department for Anaesthesia and Critical Care Medicine, Medical University, Christoph-Probst- Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, Innsbruck, 6020, Austria.
⁹ Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Naumburgstraße 15, D-38124, Braunschweig, Germany.
¹⁰ Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University, Moorenstr.5, D-40225, Duesseldorf, Germany.
¹¹ Clinic for Anaesthesia, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Wahringer Gurtel 18-20, Vienna, 1090, Austria.
¹² Universitätsklinikum Essen (AöR) Nephrology Clinic, Medizinisches Zentrum, 2.104 Hufelandstraße 55, D-45147, Essen, Germany.
¹³ Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Saarland University Hospital, D-66424, Homburg, Germany.
¹⁴ Fraunhofer IZI Rostock, Schillingallee 68, 18057, Rostock, Germany.
¹⁵ Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, London, SE1 9RT, UK.
¹⁶ Department for Nephrology, Hypertension, Dialysis and Transplantation, School of Medicine, UHC Zagreb Croatia, University of Zagreb, Šalata ul. 2, Zagreb, 10000, Croatia.
¹⁷ Department for Anesthesiology, Intensive Care Medicine, Pain Therapy and Emergency Medicine, GNH Klinikum Kassel, Mönchebergstraße 41-43, D-34125, Kassel, Germany.
¹⁸ Department of Anesthesiology, LMU University Hospital, LMU Munich, Geschwister-Scholl- Platz 1, D-80539, München, Germany.
¹⁹ Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Kirrberger Str. 100, D-66421, Homburg/Saar, Germany.
²⁰ Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, H-1082, Hungary.
²¹ Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Collegium Maius, Fredry 10, Poznan, 61-701, Poland.
²² CytoSorbents Europe, Müggelseedamm 131, D-12587, Berlin, Germany.
²³ Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany.

PMID: 39085790
PMCID: PMC11293130
DOI: 10.1186/s12882-024-03679-8

Abstract

Background: Rhabdomyolysis describes a syndrome characterized by muscle necrosis and the subsequent release of creatine kinase and myoglobin into the circulation. Myoglobin elimination with extracorporeal hemoadsorption has been shown to effectively remove myoglobin from the circulation. Our aim was to provide best practice consensus statements developed by the Hemoadsorption in Rhabdomyolysis Task Force (HRTF) regarding the use of hemadsorption for myoglobin elimination.

Methods: A systematic literature search was performed until 11th of January 2023, after which the Rhabdomyolysis RTF was assembled comprising international experts from 6 European countries. Online conferences were held between 18th April - 4th September 2023, during which 37 consensus questions were formulated and using the Delphi process, HRTF members voted online on an anonymised platform. In cases of 75 to 90% agreement a second round of voting was performed.

Results: Using the Delphi process on the 37 questions, strong consensus (> 90% agreement) was achieved in 12, consensus (75 to 90% agreement) in 10, majority (50 to 74%) agreement in 13 and no consensus (< 50% agreement) in 2 cases. The HRTF formulated the following recommendations: (1) Myoglobin contributes to the development of acute kidney injury; (2) Patients with myoglobin levels of > 10,000 ng/ml should be considered for extracorporeal myoglobin removal by hemoadsorption; (3) Hemoadsorption should ideally be started within 24 h of admission; (4) If myoglobin cannot be measured then hemoadsorption may be indicated based on clinical picture and creatinine kinase levels; (5) Cartridges should be replaced every 8-12 h until myoglobin levels < 10,000 ng/ml; (6) In patients with acute kidney injury, hemoadsorption can be discontinued before dialysis is terminated and should be maintained until the myoglobin concentration values are consistently < 5000 ng/ml.

Conclusions: The current consensus of the HRTF support that adjuvant hemoadsorption therapy in severe rhabdomyolysis is both feasible and safe and may be an effective method to reduce elevated circulating levels of myoglobin.

Keywords: Acute kidney injury; Blood purification; CytoSorb; Hemoadsorption; Renal replacement therapy; Rhabdomyolysis.

PubMed Disclaimer

Conflict of interest statement

LGF reports research support from Baxter and consultancy and speaker honoraria from Biomerieux, Fresenius and Exthera Medical. FA reports research funding by Estor and speaker support from Vifor, AstraZeneca, Amgen, Sanofy, and Aferetica. GB reports no conflicts of interest. SB reports lecture honoraria from Cytosorbents and Exthera Medical. VC reports no conflicts of interest. DF reports support from Astra Zeneca, Baxter, BBraun, Cytosorb, CSL Behring, LFB-France, Mitsubishi Pharma, Octapharm, Pfizer, Portola, US Army, Werfen. JK reports speaker honoraria from Baxter, CytoSorbents, ExThera Medical and Fresenius Medical Care. DKM reports lecture honoraria from Amboss, Biotest, Cardiotours, Cytosorbents, Diamed, Fresenius Medical Care, Medupdate, Orion Pharma. CK reports lecture honoraria from Cytosorbents. AK reports speakers honoraria for; Alexion Pharma, Astellas, Bayer Vital, Chiesi, GSK, Janssen Cilag, Kyowa Kirin, Neovii Biotech, Novartis, Otsuka, Sanofi, Vifor Fresenius, and consultant honoria for; Alexion Pharma, Astra Zeneca, CytoSorbents, GSK, Vifor Pharma, Stadapharm. He also reports being President of Deutsche Gesellschaft für Nephrologie (DGFN) - (03/2018-09/2019), Deutsche Gesellschaft für Nephrologie (DGFN) - Past President (10/2019 until today KfH-Ärztlicher BeiratAM reports honoraria for lectures from Cytosorbents. SM reports speaker honoraria, travel support and research finding from CytoSorbents Europe. MO reports research honoraria for Baxter, Biomerieux and La Jolla Pharma. VP reports no conflicts of interest. CR reports speaker honoraria from Cytosorbents. CS reports speaker honoraria from Cytosorbents. SS reports no conflicts of interest. ZM reports Senior Medical Director, CytoSorbents Europe. AZ reports consulting honoraria from Astute-Biomerieux, Baxter, Bayer, Novartis, Guard Therapeutics, AM Pharma, Paion, Fresenius, research funding from Astute-Biomerieux, Fresenius, Baxter, and speakers honoraria from Astute-Biomerieux, Fresenius, Baxter.

References

1. Bywaters EG, Beall D. Crush injuries with impairment of renal function. Br Med J. 1941;1(4185):427–32. 10.1136/bmj.1.4185.427. 10.1136/bmj.1.4185.427 - DOI - PMC - PubMed
1. Bywaters EG. Crushing Injury. Br Med J. 1942;2(4273):643–6. 10.1136/bmj.2.4273.643. 10.1136/bmj.2.4273.643 - DOI - PMC - PubMed
1. Greaves I, Porter K, Smith JE, et al. Consensus statement on the early management of crush injury and prevention of crush syndrome. J R Army Med Corps. 2003;149(4):255–9. 10.1136/jramc-149-04-02. 10.1136/jramc-149-04-02 - DOI - PubMed
1. Bagley WH, Yang H, Shah KH, Rhabdomyolysis. Intern Emerg Med. 2007;2(3):210–8. 10.1007/s11739-007-0060-8. 10.1007/s11739-007-0060-8 - DOI - PubMed
1. Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care. 2005;9(2):158–69. 10.1186/cc2978. 10.1186/cc2978 - DOI - PMC - PubMed

Publication types

Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions

Substances

Actions

LinkOut - more resources

Full Text Sources
- BioMed Central
- PubMed Central
Miscellaneous
- NCI CPTAC Assay Portal

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force

Affiliations

Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources

Miscellaneous