Fulminant rhabdomyolysis after prolonged radical prostatectomy managed with continuous veno-venous haemodialysis, regional citrate anticoagulation, and a polysulphone high-flux filter

Abstract

We present data from a patient with fulminant rhabdomyolysis (RML) after radical prostatectomy, which could be managed successfully with early initiation of continuous veno-venous haemodialysis (CVVHD). A 58-yr-old male was admitted to our hospital with the diagnosis of a carcinoma of the prostate, planned for a radical prostatectomy. The patient had a history of essential hypertension, hyperlipidaemia, and penicillin allergy, and was on atorvastatin, nebivolol, perindopril, indapamide, and spironolactone. The radical prostatectomy was performed under balanced anaesthesia with fentanyl, desflurane, and atracurium. After laparotomy, surgery was continued in the extreme Trendelenburg position (at an angle of 45°) and controlled hypotension during exposure of Santorini's venous plexus. Because of technically difficult surgical conditions, a blood loss of ∼2100 ml occurred. In total, the patient received 600 ml of erythrocyte-concentrate, 1500 ml of hydroxyethyl starch, and 3000 ml of crystalloid fluids. Arterial blood gases, obtained after 4 h of surgery, showed stable conditions. After 7 h, the operation was finished and the extreme Trendelenburg position was ended. Haemodynamic conditions became unstable despite adequate volume load, and norepinephrine was administered up to 0.20 µg kg−1 min−1. About 1 h later, the patient was transferred to the intensive care unit (ICU) where blood gases showed a severe lactic acidosis (pH 7.26; lactate 5.7 mmol litre−1) and a serum potassium of 5.7 mmol litre−1. Laboratory tests revealed an increase in creatine kinase (>8000 U litre−1) and myoglobin (586 µg litre−1) confirmed a diagnosis of RML, and forced diuresis was started. About 8 h after surgery, oligo-anuria and acute renal failure (ARF) were apparent. Because of the high risk of postoperative bleeding, CVVHD with regional citrate anticoagulation was established (Multifiltrate® with integrated Ci-Ca® system; Fresenius Medical Care, Germany). After 7 days of successful CVVHD, intermittent dialysis was established and after a further 5 days, renal replacement therapy (RRT) could be ceased. The maximum of CK was reached at day 2 (74 072 U litre−1) (Fig. 1). The patient was able to leave the hospital 35 days after surgery with no residual damage. In this case, several causes of RML have to be considered. The prolonged surgery (7 h) in a steep Trendelenburg position, high blood loss, permissive hypotension, and resultant poor perfusion of the lower limb could all have contributed.1Huerta-Alardin AL Varon J Marik PE Bench-to-bedside review: rhabdomyolysis—an overview for clinicians.Crit Care. 2005; 9: 158-169Crossref PubMed Scopus (547) Google Scholar In addition, the patient's long-term medication included atorvastatin, which is associated with RML.2Thompson PD Clarkson P Karas RH Statin-associated myopathy.J Am Med Assoc. 2003; 289: 1681-1690Crossref PubMed Scopus (1183) Google Scholar After the development of ARF, we had to decide whether to start continuous veno-venous haemodiafiltration with systemic anticoagulation or to commence CVVHD with regional citrate anticoagulation. It is reported that continuous veno-venous haemofiltration is more effective in myoglobinuric ARF at clearing myoglobin, a major factor in renal toxicity, from the systemic circulation.3Naka T Jones D Baldwin I et al.Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report.Crit Care. 2005; 9: R90-R95Crossref PubMed Google Scholar However, in our case, ARF occurred immediately after a surgical procedure with a high blood loss, and a recent study4Sorrentino SA Kielstein JT Lukasz A et al.High permeability dialysis membrane allows effective removal of myoglobin in acute kidney injury resulting from rhabdomyolysis.Crit Care Med. 2011; 39: 184-186Crossref PubMed Scopus (38) Google Scholar described the effective elimination of myoglobin by haemodialysis. As we had the opportunity to use the same polysulphone high-flux filter (Ultraflux AV 1000 S®, Fresenius Medical Care) as described in this study, we elected to start CVVHD with regional citrate anticoagulation and this filter to avoid secondary bleeding. After an increase in myoglobin during the first 3 days on ICU due to ongoing RML (maximum at day 3: 20 600 µg litre−1; Fig. 1), this management resulted in a good clearance of myoglobin and return of normal function after a long recovery. The recent development of high-flux filters with an enhanced middle molecule clearance could even improve the efficacy of CVVHD in myoglobinuric ARF. To our knowledge, there are no other reports of fulminant RML immediately after surgical procedures managed with CVVHD and regional citrate anticoagulation yet. None declared.