Abstract: SA-PO070
Clearance of Plasma Free Hemoglobin by Therapeutic Plasma Exchange for Mechanical Hemolysis-Related Pigment-Induced AKI
Session Information
- AKI: Clinical, Outcomes, and Trials - Management
October 26, 2024 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Crane, Clarkson, University of California San Diego, La Jolla, California, United States
- Song, Alexander Hyunjoon, Stanford University School of Medicine, Stanford, California, United States
- Cruz, Dinna, University of California San Diego, La Jolla, California, United States
Introduction
Intravascular hemolysis is a complication of extracorporeal membrane oxygenation (ECMO) and associated with pigment-induced AKI and increased mortality. Elevated plasma-free hemoglobin (PFH) can promote thrombosis in an acquired thrombotic thrombocytopenic purpura (TTP) process by inhibiting von Willebrand factor (VWF) cleavage by ADAMTS13. We report use of therapeutic plasma exchange (TPE) in an attempt to reduce ECMO circuit clotting and promote AKI recovery.
Case Description
A 42-year-old woman admitted for COVID-19 respiratory failure required cannulation to ECMO. She developed thrombocytopenia and microangiopathic hemolytic anemia with LDH >2,500 U/L, elevated total bilirubin, undetectable haptoglobin, and schistocytes, attributed to ECMO-induced hemolysis. PFH was elevated 398.0 mg/dL and it was hypothesized this caused an acquired TTP-like presentation.
She subsequently developed anuric AKI attributed to pigment nephropathy. CRRT was initiated and in-line TPE started to remove PFH to stop the cycle of thrombolysis/hemolysis to potentially allow for AKI recovery. Four sessions of TPE were performed with supernatant transitioning from dark red (from PFH) to a lighter color as PFH level decreased to 4.1 mg/dL (Figure 1). LDH decreased and haptoglobin became detectable. Given these, TPE was considered successful. However, before an improvement in urine output could be demonstrated, she developed refractory septic shock and expired.
Discussion
We describe a case where PFH due to ECMO-related hemolysis was successfully removed with TPE, resulting in improved hematologic parameters and the potential for continuation of mechanical circulatory support and recovery of AKI. In similar clinical settings, this therapy has potential to provide clinical benefit and merits ongoing study.