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Introduction: The role of extracorporeal myoglobin removal in the treatment of rhabdomyolysis-associated severe acute kidney injury (AKI) is not yet fully established. High cut-off (HCO) and medium cut-off (MCO) dialysis membrane and cytokine adsorber (CytoSorb®) have been used to this purpose in clinical practice. The data on comparative effectiveness of those methods are scarce. Methods: In this single-center retrospective study, we included patients with AKI and concomitant rhabdomyolysis (myoglobin >20,000 μg/L), who underwent at least one extracorporeal myoglobin removal procedure. The main outcome parameter was myoglobin reduction ratio, whereas albumin was assessed as a safety parameter. Results: We analyzed data for 15 patients, who underwent 28 procedures (13 HCO, 9 MCO, and 6 adsorber). Pre-treatment serum myoglobin levels were similar between the groups and myoglobin reduction was significant in HCO (p = 0.03) and MCO groups (p < 0.01) and borderline significant in adsorber group (p = 0.06). Reduction ratios were comparable between the groups (median 0.64 (inter-quartile range IQR 0.13–0.72), 0.54 (IQR 0.51–0.61) and 0.50 (IQR 0.37–0.62), respectively, p = 0.83). Both pre- and post-procedure serum albumin levels were significantly lower in the MCO group. However, with routine albumin substitution in the HCO group only, serum albumin remained stable during the procedures in all subgroups. Conclusions: Novel MCO membrane might represent the optimal mode of treatment of severe rhabdomyolysis-associated AKI, as it allows for efficient removal of myoglobin, avoids albumin supplementation and is associated with lower costs. For patients requiring cytokine removal, the adsorption capsule can simultaneously reduce cytokine and myoglobin levels.

Background. Systemic inflammatory response syndrome (SIRS) is a complex pathophysiologic response to several hostile stimuli. The excessive release of cytokines during SIRS often leads to a cytokine storm causing refractory hypotension and ultimately multiple organ failure with high mortality. Cytokine removal with hemoadsorption has emerged as a possible adjuvant therapy, but data on IL-6 reduction and clinical outcomes are scarce. We aimed to evaluate the effect of CytoSorb hemoadsorption on laboratory parameters and clinical outcomes in shocked patients with SIRS. Methods. We designed a retrospective analysis of all patients with SIRS treated with CytoSorb in intensive care units. Interleukin 6 (IL-6), hemodynamic parameters (mean arterial pressure – MAP and vasoactive inotropic score - VIS), pH and lactate levels at the beginning, after 6h, 12h, 24h and 48h of CytoSorb treatment were analyzed in the whole cohort and in a subgroup of patients with septic shock. Predicted and observed mortality rates were compared using Chi-squared test. Statistical significance was defined as p Results. After screening 147 patients, we included 118 patients with various etiologies of SIRS (septic shock 69%, SIRS after cardiac arrest 16%, SIRS after acute pancreatitis 6%, other 9%). In all but one patient CytoSorb was coupled with renal replacement therapy. During the observed period of 48 hours, a statistically significant decrease in IL-6 levels, increase in pH, increase in MAP and decrease in VIS was observed already from 6h onward. Reduction of lactate levels became statistically significant at 48 hours. In a subgroup of patients with septic shock, the results were similar, and PCT levels did decreased after 24 hours. Observed ICU and in-hospital mortalities in the whole group were lower than predicted by SOFA (61% vs 79%, p=0.005) and APACHE II (64% vs 78%, p=0.031). There were no serious complications attributed to CytoSorb treatment.Conclusions. Hemoadsorption with CytoSorb used in patients with SIRS of different etiologies was associated with a rapid decrease in IL-6 and hemodynamic improvement, with improved observed vs. predicted survival. These results need to be confirmed in a randomized study.

Background and Aims Severe rhabdomyolysis often causes acute kidney injury (AKI). If severe, AKI significantly reduces myoglobin removal through the kidneys. Given molecular size of myoglobin, extracorporeal removal using newer hemodialysis membranes and adsorption techniques is possible, although its role on clinically significant outcomes is not yet fully established. We aimed to compare the efficacy of high cut-off (HCO) membrane, medium cut-off (MCO) membrane and Cytosorb® adsorber on myoglobin removal. Method In this retrospective study we included 15 patients with AKI and concomitant rhabdomyolysis with severely increased myoglobin (>20.000 µg/L), who underwent at least one extracorporeal procedure with the intention of extracorporeal myoglobin removal. There were 28 procedures performed: 13 HCO (Theralite®, Gambro) dialysis, 9 MCO (Theranova®, Gambro) dialysis and 6 adsorber (Cytosorb®, Cytosorbents) procedures. Serum myoglobin and albumin levels were recorded from the time frame of up to 12 hours prior to and up to 12 hours after the index procedure and reduction rates (RR) for myoglobin were calculated. Albumin levels were compared before and after procedure as a safety parameter. Results Treatment duration differed significantly and was the longest for Cytosorb® adsorber (median 11 h) and the shortest for MCO membrane (median 5 h). Pre-treatment serum myoglobin levels were comparable across the groups. Reduction in myoglobin during procedure was significant for HCO and MCO and borderline significant in adsorber group, with respective median RR of 0.64, 0.54 and 0.50 (p = 0.83). Routine albumin substitution was implemented only in HCO group, but serum albumin levels were stable in all subgroups. Conclusion In this preliminary observational study we found comparable effectiveness of a novel MCO and ‘standard’ HCO dialysis membrane for serum myoglobin removal in patients with severe AKI. Cytokine adsorber showed borderline effectiveness, but the number of procedures in this group was small. MCO dialysis is associated with lower costs and no need for albumin supplementation and therefore might be the optimal mode of treatment of severe rhabdomyolysis-associated AKI. For patients with multiorgan failure requiring cytokine removal and severe myoglobinemia, hemoadsorption can reduce cytokine and myoglobin levels simultaneously.

Association of higher serum levels of uremic toxins and inflammatory markers with poorer physical performance is understudied. We measured the six-minute walk test (6MWT), 10 repetition sit-to-stand test (STS-10), handgrip strength (HGS), and Human Activity Profile (HAP) questionnaire score in 90 prevalent hemodialysis patents, with low comorbidity to reduce the potential confounding of concomitant disease. Midweek pre-dialysis serum levels of asymmetric dimethyl-arginine (ADMA), &beta, 2-microglobulin (B2M), high-sensitivity C-reactive protein (hs-CRP), indoxyl sulfate (IS), insulin-like growth factor 1 (IGF-1), interleukin 6 (IL-6), myostatin, and urea were analyzed as predictor parameters of physical performance measures in adjusted models. Serum levels of most measured toxins were not significantly related to performance, except for ADMA, which was significantly related to poorer performance in the STS-10 test (B = 0.11 &plusmn, 0.03 s, p &lt, 0.01). Higher hs-CRP was associated with poorer results in the 6MWT (B = &minus, 2.6 &plusmn, 0.97 m, p &lt, 0.01) and a lower HAP score (B = &minus, 0.36 &plusmn, 0.14, p = 0.01). There were no other significant associations found. We conclude that inflammation may be a more important pathway to physical impediment than uremic toxemia. This suggests that there is a large physical rehabilitation potential in non-inflamed uremic patients.