Tpe or Not Tpe: Using Therapeutic Plasma Exchange in Severe Rhabdomyolysis

Abstract

INTRODUCTION:Rhabdomyolysis is a syndrome caused by damage to skeletal muscle and the release of its breakdown products into the circulation. It can be asymptomatic or progress to acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Therapeutic plasma exchange (TPE) also known as plasmapheresis has been reported as a treatment option but data is limited to a handful of case reports. [1,2] We report our institutional experience using TPE for rhabdomyolysis in 10 critically ill patients admitted to our ICU during 2012-2020. CASE PRESENTATION:The patient age range was from 23 -63 years (mean 41.4 years) and predominantly male (n¼8). The most common etiologies were traumatic (n¼4), amphetamine-induced (n¼2), and acute limb ischemia, heat-stroke, electrocution, sepsis, and cardiogenic shock. Six patients had no major medical comorbidities, while others had concomitant COPD, heart failure, atrial fibrillation with mesenteric ischemia, and traumatic subdural hemorrhage. Initial creatinine (Cr) ranged from 1.9 to 8 mg/dl (mean 4.0), creatinine phosphokinase (CPK) from 6,000-100,000 U/L, and myoglobin from 5000 to >20,000 ng/ml. All patients had acute renal failure and eight of them had at least one other organ dysfunction such as respiratory failure (n¼7), shock (n¼6), liver injury (n¼1), or encephalopathy (n¼2). SOFA scores ranged from 3-18 (mean 7.85). All patients required continuous veno-venous hemofiltration due to renal impairment. TPE was started within 48 hours of diagnosis. PRISMAX machines with TPE2000 filters were used to perform TPE via membrane plasma separation. Either 5% albumin or fresh frozen plasma were exchanged at a filtration fraction of 25%. Patients underwent 1-3 TPE sessions (mean 1.4). A decrease in myoglobin, CPK, and Cr was seen post-TPE. Six patients had resolution of condition with successful discharge from ICU. Two patients deceased secondary to multi-organ failure and two were transitioned to comfort care due to concomitant neurotrauma and poor prognosis. Length of ICU stay ranged from 3-14 days (mean 7.5). Among survivors, only one patient required renal replacement therapy (RRT) upon hospital discharge. All patients had complete resolution of kidney dysfunction at a 3-month follow-up. No complications due to TPE were seen.DISCUSSION: There are no RCTs evaluating optimal treatments for rhabdomyolysis, however, case series using TPE in severe rhabdomyolysis have reported favorable outcomes. Our case series shows similar findings and suggests that TPE was effective in clearing circulating myoglobin as well as potentially other cytokines which are thought to propagate the disease process [3].CONCLUSIONS: TPE can be safely and effectively used to treat severe rhabdomyolysis with multiorgan dysfunction. Further studies are required to elucidate its exact role in preventing long-term kidney dysfunction