High Cutoff Membrane to Reduce Systemic Inflammation Due to Differentiation Syndrome: A Case Report

Abstract

Background: Differentiation syndrome is a life-threatening complication of therapy that is carried out with agents used for acute promyelocytic leukemia. Its physiopathology comprehends the production of inflammatory mediators by differentiating granulocytes, endothelial and alveolar cells due to stimulation by all-trans retinoic acid and leading to sustained systemic inflammation. Methods: Treatment with high cut-off continuous veno-venous hemodialysis (HCO-CVVHD) was performed to reduce the circulating mediators of systemic inflammation. Results: After 52 h of treatment, an important reduction was observed in inflammatory mediators (IL-1β: from 10 to 2 pg/ml; IL-8: from 57 to 40 pg/ml; TNF-α: from 200 to 105 pg/ml; IL-6: from 263 to 91 pg/ml), as well as in anti-inflammatory mediators (IL-10: from 349 to 216 pg/ml). Conclusions: HCO-CVVHD should be explored as a part of treatment in systemic inflammation states other than sepsis (e.g., differentiation syndrome). Furthermore, its immunomodulatory effects could be particularly useful in immunocompromised patient treated with corticosteroids.

Albumin Loss and Citrate Load in Pre-Dilution High Cut-Off-CVVHDF with Regional Citrate (18 mmol/L) and High Cut-Off CVVHD with Systemic Heparin: An in vitro Study

“…Membrane fouling is a critical factor for a rapid decline of transmembrane clearance (particularly for large molecules), for discrepancies between the current dose and the current effective delivered dose and for premature interruption of the extracorporeal treatment [13, 21]. Thus, membrane fouling is particularly harmful in extracorporeal blood purification therapies, such as HCO-CVVHD, performed in septic AKI patients to remove large molecules (e.g., cytokines) [15]. …”

“…Indeed, isotonic citrate solutions are usually contraindicated for regional anticoagulation during HCO treatments for the increase in transmembrane pressure induced by the citrate prefilter infusion [9, 15]. Several authors have advocated the use of HCO membrane with a high-volume convective technique to increase the transmembrane removal of inflammatory mediators [22, 23]; however, most users prefer a purely dialytic therapy to prevent the potential unwanted albumin release.…”

“…Unfortunately, the systemic heparinization is usually not applicable in septic patients with AKI undergoing HCO-CVVHD because of high risks of bleeding due to septic-induced coagulopathy and for the often-required surgical source control of the infection site. Although the most recent KDIGO guidelines [14] suggest the use of a regional anticoagulation with citrate for most CRRT patients, several concerns derive from the adoption of such therapy in septic patients treated with HCO [15]. In particular, the infusion of isotonic citrate in the extracorporeal circuit is theoretically avoided with HCO, mainly because of the potential albumin loss deriving from the application of a transmembrane pressure across the hemofilter [15].…”

“…Although the most recent KDIGO guidelines [14] suggest the use of a regional anticoagulation with citrate for most CRRT patients, several concerns derive from the adoption of such therapy in septic patients treated with HCO [15]. In particular, the infusion of isotonic citrate in the extracorporeal circuit is theoretically avoided with HCO, mainly because of the potential albumin loss deriving from the application of a transmembrane pressure across the hemofilter [15]. Moreover, the alternative use of hypertonic citrate is (1) potentially associated with harmful electrolyte alterations, mainly in patients with septic shock and/or sepsis induced-liver failure; (2) it usually requires customized solutions and (3) it is not available for all CRRT machines [15].…”

Impact of serum and dialysates obtained from chronic hemodialysis patients maintained on high cut‐off membranes on inflammation profile in human THP‐1 monocytes

“…21,22 Their ability to remove large quantities of inflammation mediators makes the HCO membranes a promising tool for chronic HD patients with elevated CRP level. 23,24 In this study, we investigated the effects of serum and dialysates obtained from patients treated either with HCO or HF membranes within a randomized crossover pilot trial. 25 Therefore, we applied these fluids to human THP-1 monocytes in vitro and tested whether HCO treatment could remove proinflammatory substances from serum to the dialysate.…”