Abstract: FR-PO654
Back from the Cold!
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Padala, Sandeep, Augusta University, Augusta, Georgia, United States
- Saleem, Muhammad Omar, Augusta University, Augusta, Georgia, United States
- Mohammed, Azeem, Augusta University, Augusta, Georgia, United States
Introduction
Continuous Renal replacement therapy (CRRT) can modulate core body temperature through modulation of the replacement fluid temperature. Although this has been theorized to be helpful in hypotension, there are no guidelines for a temperature setting during CRRT. We present a case where maintaining an optimal temperature during CRRT was of paramount importance to the overall patient management.
Case Description
A 32-year-old African American male presented to the emergency room with recurrent syncope and was notably pale and lethargic on arrival. Lab tests revealed hemolytic anemia with hemoglobin of 3.3 g/dL, LDH of 991 U/L, haptoglobin of 1 mg/dL, positive C3 and total bilirubin of 4.3 mg/dL. A peripheral smear showing severe anemia, prominent agglutination and several granulocytes containing intracytoplasmic cryoglobulins was conclusive for cold agglutinin disease. Although steroids and plasmapheresis were started, patient’s condition worsened with the development of multiorgan failure, shock and oliguric renal failure from acute tubular necrosis.
We instituted emergent initiation of CRRT for correction of malignant hyperkalemia and acidosis in the setting of hemodynamic instability. Patient underwent 5 days of CRRT with concomitant plasmapheresis. To assist with the overall therapeutic warming strategy, the Replacement fluid was heated on an external heating device and via the CRRT machine to the maximum temperature of 38 C. He improved significantly with resolution of acidosis, and electrolyte derangements; he ultimately required rituximab to truncate the autoimmune hemolytic anemia. A repeat cold agglutinin assay confirmed IgG+ cold agglutinin disease with a positive Mycoplasma IgM thought to be the likely trigger of the autoimmune hemolytic anemia.
Discussion
This case provides a unique perspective on temperature control during CRRT. Typically, cooling of dialysate or replacement fluid is used to bolster blood pressure in times of hemodynamic shock. In this setting, the reverse was utilized as a therapeutic benefit. While often overlooked as a part of the routine CRRT order set, this case highlights the important impact that temperature modulation can have on overall patient management, and should be carefully considered when approaching the CRRT prescription.