High Cut‐Off Membrane Hemodiafiltration in Myoglobinuric Acute Renal Failure: A Case Series

Abstract

Acute renal failure is a major complication of rhabdomyolysis. New membranes for hemodialysis have been developed with a high cut-off pore size allowing efficient removal of myoglobin. We report on six patients treated by hemodiafiltration with a high cut-off membrane (HCO-HDF) for myoglobinuric acute renal failure. Rhabdomyolysis was caused by infection in two patients, by a statin in one patient and a non-traumatic crush in another, and followed cardiovascular surgery in two others. Ten HCO-HDF procedures were performed. A high cut-off hemofilter was used, with citrate anticoagulation and postdilutional fluid substitution of 2-3 L/h, dialysate flow 500 mL/min, and blood flow within 250-300 mL/min. Albumin losses were replaced by infusion of human albumin solution, and the mean myoglobin reduction ratio was 77% (range, 62-89%). An excellent clearance of 81 mL/min (range 42-131 mL/min) was achieved. Nearly 5 g of myoglobin was removed into the dialysate collected in one of the procedures. A high rebound in serum myoglobin, on average to 244% of the post-procedure myoglobin level, was observed. The four patients alive at the time remained anuric for a week. Slow myoglobin elimination with a mean half-time of 39 h (range 19-59 h) was observed in that period. Highly efficient myoglobin removal by high cut-off membrane hemodiafiltration was demonstrated in our patients. Rapid redistribution from the extracellular fluid and sustained myoglobin release were suggested by the high rebound observed. Elimination of myoglobin within the body was shown in our study to occur slowly during the period of anuria.

High Cut-Off Renal Replacement Therapy for Removal of Myoglobin in Severe Rhabdomyolysis and Acute Kidney Injury: A Case Series

“…HCO devices are CE certified and used in different clinical indications, among them elimination of cytokines in sepsis or serum free light chains in multiple myeloma. Only recently, improved myoglobin elimination has been reported for these filters in individual cases [25,26,27]. …”

Cytokine Removal with High Cut-Off Membrane: Review of Literature

“…On the other hand, HCO showed an increased retention onset, defined as the mean value of the molecular weight of those molecules with an SC equal to 0.9, clinically represented by the molecular weight of the smallest molecule which is subjected to transmembrane retention. The higher retention onset allows to increase and maintain clearance of molecules with a lower molecular weight for longer periods of time, that is, myoglobin (18 kDa) [12], β2-microglobulin (12 kDa) [13], and interleukin-8 (8 kDa) [14]. The adhesion of proteins to the membrane surface commonly occurs during the treatment, and this new layer (‘protein cake') acts as a barrier that further affects the transmembrane clearance by means of pore occlusion.…”

Myoglobin Removal Using High-Volume High-Flux Hemofiltration in Patients with Oliguric Acute Kidney Injury

“…Previous studies evaluating hemofiltration for myoglobin clearance have been small and contradictory [8,9,10,11,12,13,14,15,16,17,18] (table 3). Similar to ours, in these studies the sieving coefficient was greater at the beginning of the treatment and decreased over time.…”

“…It appears in the urine only when the renal threshold of 0.5-1.5 mg/dl of myoglobin is exceeded and is visible (as dark urine) when 100 mg/dl of myoglobin is reached [2]. In addition to standard medical care including aggressive volume resuscitation and urinary alkalinization, it has been suggested that elimination of myoglobin might be enhanced by a blood purification modality based on convective clearance and that its removal will decrease the risk of AKI in high-risk patients [8,9,10,11,12,13,14,15,16]. It remains controversial whether or not significant clearance can be obtained beyond that achieved through both renal and extrarenal mechanisms.…”