Myoglobin clearance with continuous veno-venous hemodialysis using high cutoff dialyzer versus continuous veno-venous hemodiafiltration using high-flux dialyzer: a prospective randomized controlled trial

Abstract

Background Myoglobin clearance in acute kidney injury requiring renal replacement therapy is important because myoglobin has direct renal toxic effects. Clinical data comparing different modalities of renal replacement therapy addressing myoglobin clearance are limited. This study aimed to compare two renal replacement modalities regarding myoglobin clearance. Methods In this prospective, randomized, single-blinded, single-center trial, 70 critically ill patients requiring renal replacement therapy were randomized 1:1 into an intervention arm using continuous veno-venous hemodialysis with high cutoff dialyzer and a control arm using continuous veno-venous hemodiafiltration postdilution with high-flux dialyzer. Regional citrate anticoagulation was used in both groups to maintain the extracorporeal circuit. The concentrations of myoglobin, urea, creatinine, β2-microglobulin, interleukin-6 and albumin were measured before and after the dialyzer at 1 h, 6 h, 12 h, 24 h and 48 h after initiating continuous renal replacement therapy. Results Thirty-three patients were allocated to the control arm (CVVHDF with high-flux dialyzer) and 35 patients to the intervention arm (CVVHD with high cutoff dialyzer). Myoglobin clearance, as a primary endpoint, was significantly better in the intervention arm than in the control arm throughout the whole study period. The clearance values for urea and creatinine were higher in the control arm. There was no measurable albumin clearance in both arms. The clearance data for β2-microglobulin and interleukin-6 were non-inferior in the intervention arm compared to those for the control arm. Dialyzer lifespan was 57.0 [38.0, 72.0] hours in the control arm and 70.0 [56.75, 72.0] hours in the intervention arm (p = 0.029). Conclusions Myoglobin clearance using continuous veno-venous hemodialysis with high cutoff dialyzer and regional citrate anticoagulation is better than that with continuous veno-venous hemodiafiltration with regional citrate anticoagulation. Trial registration German Clinical Trials Registry (DRKS00012407); date of registration 23/05/2017. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012407.

Clearance of inflammatory cytokines in patients with septic acute kidney injury during renal replacement therapy using the EMiC2 filter (Clic-AKI study)

“…For instance, a previous study demonstrated higher IL-6 and IL-8 clearance by the EMiC2 filter than the standard membrane, but showed no significant impact on plasma cytokine concentrations [ 26 ]. Another study showed comparable IL-6 clearance between the EMiC2 and high-flux membrane [ 27 ]. Similarly, studies using the EMiC2 or HCO membranes reported no changes in plasma concentrations despite detectable clearance in the ultrafiltrate [ 11 , 15 , 28 , 50 ].…”

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

“…Heyne et al [ 12 ] described this approach in a case series with an effective removal of myoglobin. Furthermore, Weidhase et al [ 13 ] recently published the results of a randomized trial, where a higher myoglobin clearance can be seen in patients treated with HCO dialyzers in contrast to the typically used high-flux dialyzers. Both had the same surface area of 1.8 m 2 and myoglobin clearance was about 8–10 ml/min for HCO dialyzers and 2–3 ml/min for high-flux dialyzers.…”

Extracorporeal myoglobin removal in severe rhabdomyolysis with high cut-off membranes—intermittent dialysis achieves much greater clearances than continuous methods

“…Weidhase et al recently published a randomized controlled trial comparing two renal replacement modalities regarding myoglobin clearance [ 1 ]. The authors found superior myoglobin clearance with a high cut-off (HCO) dialyzer running in continuous veno-venous hemodialysis (CVVHD) mode compared to a standard, high-flux dialyzer running in continuous veno-venous hemodiafiltration (CVVHDF) mode [ 1 ], which is not surprising, given the properties of HCO membranes.…”

“…Weidhase et al recently published a randomized controlled trial comparing two renal replacement modalities regarding myoglobin clearance [ 1 ]. The authors found superior myoglobin clearance with a high cut-off (HCO) dialyzer running in continuous veno-venous hemodialysis (CVVHD) mode compared to a standard, high-flux dialyzer running in continuous veno-venous hemodiafiltration (CVVHDF) mode [ 1 ], which is not surprising, given the properties of HCO membranes. HCO dialyzers were first used in intermittent hemodialysis with the aim of free light chains [ 2 ] and myoglobin removal [ 3 ], but have later also been used with continuous dialysis techniques, mainly with the aim of improving clearance of inflammatory cytokines.…”

“…The authors concluded that CVVHD using HCO dialyzers could be beneficial in patients with acute kidney injury and high myoglobin levels [ 1 ]. We would like to emphasize that intermittent hemodialysis would be more suitable than continuous methods for the treatment of severe rhabdomyolysis-associated acute kidney injury (AKI).…”