P0635MYOGLOBIN CLEARANCE IN CVVHD USING HIGH CUT-OFF FILTER VERSUS CVVHDF WITH REGIONAL CITRAT ANTICOAGULATION: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Authors: De Fallois Jonathan , Weidhase Lorenz , Petros Sirak 
Published: June 2020

Abstract

Background and Aims
Acute kidney injury (AKI) is frequent among critically ill patients and it is associated with high mortality. Rhabdomyolysis is a distinct cause of AKI. As myoglobin has renal toxic effects, clearance via continuous renal replacement therapy (CRRT) may be favourable. Current international guidelines recommend regional citrate anticoagulation (RCA).
Clinical data comparing different modalities of CRRT addressing myoglobin clearance are lacking. Hemofiltration is recommended to eliminate myoglobin, which requires systemic anticoagulation. RCA would be impractical due to the high citrate load as a result of the higher blood flow.
Continuous veno-venous hemodiafiltration (CVVHDF) is one opportunity to realize lower citrate load and maintain middle molecule clearance. Another approach may be the application of hemodialysis with high cut-off (HCO) membranes with a pore size larger than 0.01 μm in CVVHD (CVVHD-HCO). We have previously shown that CVVHD-HCO is superior to conventional high-flux dialyser regarding the clearance of β2-microglobulin. Based on this finding, we analyzed of various etiologiesre Filter lilifespan mit dem efonnummer der Virologie zum Befunderfragenmyoglobin clearance with CVVHDF compared to CVVHD-HCO with RCA.

Method
The present study is a prospective, randomized, single-blinded, monocentric trial. We enrolled patients from May 2017 to September 2018 in our 28-bed medical ICU at the University Hospital Leipzig.
We screened 430 patients with AKI and indication for RRT for eligibility. A total of 70 patients underwent randomisation 1:1 into the intervention (CVVHD-HCO, high cut-off dialyzer Ultraflux EMiC2) and control group (CVVHDF, high-flux dialyzer Ultraflux AV1000S).
The concentrations of myoglobin (17053 Dalton (Da), urea (60 Da), creatinine (113 Da), β2-microglobulin 11800 Da), interleukin 6 (IL-6, 26000 Da) and albumin (66470 Da) were measured before (pre) and after (post) the dialyzer 1, 6, 12, 24 and 48 h after initiating CRRT.
We hypothesized non-inferiority of CVVHD-HCO versus CVVHDF regarding myoglobin clearance (primary end-point).

Results
Myoglobin clearance showed non-inferiority in the intervention group for all time points. The dialyzer in the intervention group resulted in even a better myoglobin clearance during the whole study period. (Table 1).
Clearance values for urea and creatinine were equal and there was no albumin loss in both groups.β2-microglobulin clearance was significantly better in the intervention group than in the control group at all time points. The clearance of IL-6 was also better at T0 in the intervention group. The filter lifespan was 51.5 hours (CI: 44.24; 58.76) in the control group and 62.3 hours (CI 56.83; 67.7) in the intervention group (log-rank, p=0,029).

Conclusion
Myoglobin can be reliably cleared using both CVVHD-HCO and CVVHDF. Nevertheless, the plasma specific clearance rate of myoglobin was higher with CVVHD-HCO. High myoglobin levels are associated with AKI and higher mortality rates and on this account clearance of myoglobin represents a relevant clinical issue.