Use of Continuous Venovenous Hemodiafiltration with a High Cutoff Membrane in a Patient with Severe Acute Pancreatitis

Abstract

In patients with severe acute pancreatitis (SAP) early and persistent elevated circulating levels of interleukins (IL)-1, 2 and 6 and tumor necrosis factor (TNF)-α are linked to severity of disease and early multiple organ failure (MOF), while persistently elevated serum IL-10 is linked to immune paralysis and infectious complications. Although experimental and clinical evidence exists that continuous venovenous hemodiafiltration with high cutoff membranes (HCO-CVVHDF) efficiently removes inflammatory mediators from blood of patients with severe sepsis or septic shock, data are lacking on the subset of patients with SAP, particularly in cases with uninfected necrosis. We treated with HCO-CVVHDF a 59-year-old man admitted to our intensive care unit (ICU) with SAP inducing early-onset cardiovascular, respiratory and renal dysfunctions associated with high circulating levels of IL-6 and TNF-α and without overt clinical or laboratory signs of infection. During the treatment, cardiovascular, respiratory and renal functions rapidly normalized and circulating levels of IL-6 and TNF-α consistently decreased. The patient was discharged from ICU on day 20.

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

“…An increase in cardiac output (from 5.9 to 8.4 l/min) and mean arterial pressure (77.5-80 mm Hg) were observed at 12 h of treatment, with a concomitant reduction in norepinephrine requirement (0.26 to 0.19 μg/kg/min) [34]. Comparable findings have been shown in non-septic patients treated with HCO membranes, with an improvement in hemodynamic parameters and in indices of oxygenation [3] (fig. 1).…”

“…In particular, Kade et al reported a reduction in IL-4, IL-6, IL-10, and IL-12 in a patient with multiple organ dysfunction due to sepsis and following cardiac arrest [16]. Chelazzi et al reported the use of continuous hemodialysis with HCO membrane for severe acute pancreatitis (SAP), recording a net reduction of hematic cytokine concentration, specially of IL-6, which is recognized as one of the most important molecules in SAP pathophysiology [3]. …”

“…In other words, a particular patient would be able to produce and release a vast amount of these mediators, and in some cases, overexpress them in relation to the etiological stimulus. This impairment in regulation of cytokines is recognized as a main pathophysiological mechanism in the systemic inflammatory syndromes (i.e., sepsis or severe acute pancreatitis), common among critically ill patients [1,3,4]. …”

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

“…For example, Chelazzi et al reported the use of HCO-CVVHD for severe acute pancreatitis (SAP) in absence of sepsis. They reported a net reduction of serum cytokine concentrations during the treatment, in particular of IL-6, recognized as one of the most important molecules in the physiopathology of SAP [11]. …”

“…An improvement in the hemodynamic parameters and oxygenation indices are usually reported both in sepsis-related and non-sepsis related multiple organ dysfunction, treated with high cutoff membranes (HCO) [11,12,13]. By increasing the membrane pore size (internal radius >0.01 μm, cut-off 60 kDa), the extent of molecules cleared is significantly broadened [14].…”