P1121TOTAL PLASMA EXCHANGE (TPE) AND CITRATE CRRT IN A LOW-WEIGHT PEDIATRIC PATIENT WITH MACROPHAGE ACTIVATION SYNDROME (MAS): FEASIBILITY AND COMPLEXITIES OF BOTH TREATMENTS

Abstract

Abstract Background and Aims Low-weight extracorporeal pediatric dialysis treatments remain a challenge due to their clinical and technical complexity. Apart from some metabolic congenital disorders, the usual indications for CRRT in early pediatric patients and newborns are the same as for adults with acute kidney injury (AKI). But the implementation of TPE is still in the anecdotal stage. Method Clinical case: a 7-month female infant, weighing 5.7kg, in the neonatal intensive care unit with fever, lymphadenopathy, hepatosplenomegaly, pancytopenia, hyperferritinemia, hypertriglyceridemia, was diagnosed as having macrophage activation syndrome (MAS). She developed AKI and acute respiratory distress syndrome (ARDS), due to sepsis. Because of oliguria, ruling out administration of drugs and parental nutrition, and fluid overload (more than 20% of her body-weight), CRRT was started. Results CRRT lasted 22 days in continuous venovenous hemodiafiltration (CVVHDF), with regional citrate anticoagulation (Table 1). Mean filter patency: 26±17h. 43% of treatments were interrupted after CVC failure, 21% after clinical procedures, 7% after filter coagulation. There was in this case no citrate accumulation and satisfactory metabolic and electrolyte control were obtained (Figure 1). After treatment of MAS failed with both i.v. immunoglobulins and corticosteroids, we considered TPE as a rescue therapy for the disease, even though we could not find a similar experience reported in the literature in such a small infant. We performed 3 TPE sessions, with heparin anticoagulation (Table 1), non-consecutively, with CRRT in between. Conclusion The treatments were well tolerated, resulting in a large decrease in triglycerides and ferritin (MAS index, Figure 2). Despite the death of the patient after ARDS worsened, we showed that even in a small critically ill infant, complex depurative treatments such as total plasma exchange are feasible. Highly skilled nephrologists and dialysis nurses are mandatory for treatment management.