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Role of Early Initiation of Continuous Veno-Venous Hemofiltration (CVVH) for Management of Sinusoidal Obstructive Syndrome (SOS) Following Stem Cell Transplant (SCT)
INTRODUCTION
SOS, a syndrome characterized by hepatic sinusoidal obstruction, is a frequent cause of acute kidney injury (AKI) following SCT. In this setting, mortality rates are >90% despite aggressive therapy. While defibrotide has emerged as a therapeutic option for many patients with SOS, managing fluid overload (FO) and electrolyte and acid base balance in the context of AKI remains a significant challenge.
OBJECTIVE:
We retrospectively reviewed our effort to standardize our approach in patients with AKI and FO due to SOS following SCT.
METHODS:
From 9/11 to 9/13, 44 SCT were performed. Six (13.6%) developed AKI and FO related to SOS. All patients were treated with fluid/sodium restriction and diuretics prior to initiation of CVVH. Early indications for CVVH included diuretic-resistant FO >5% and oligo/anuric AKI. We performed 57 CVVH procedures (procedure = 24 hours) with pre and post dilution using citrate or heparin anticoagulation.
RESULTS:
(Table 1) Four of six patients (66%) had complete recovery (CR) of SOS symptoms (mean recovery time 5 days). CVVH was initiated within 16 hrs after diagnosis of FO or oligo/anuric AKI. Mean time on CVVH was 9 days. The median patency of the CVVH tubing set was 3.5 days. Defibrotide was used in 50% of patients. Citrate anticoagulation was used in 5 of 6 patients, and was well tolerated. Only 1 of 5 developed citrate gap, which resolved after adjusting citrate rate. No serious hemorrhagic events were observed. Two of 6 patients died (34%) – Case #1 due to SOS, and #5 due to systemic CMV infection. These corresponded to the patients with the highest FO.
TABLE 1
Case #
| 1 | 2 | 3 | 4 | 5 | 6 |
Reason for SCT
| BLS 2;
| MDS
| CML
| AML
| MDS
| AML
|
Conditioning
| Bu/Cy/
| Bu/Cy
| Bu/Cy/ ATG
| Bu/Cy/
| Bu/Cy/
| Bu/Cy/
|
Stem cell source
| BM
| PBSC
| D-UCB
| BM
| PBSC
| BM
|
%wt gain at onset of SOS | 40
| 9
| 5
| 10
| 20
| 10
|
Bili/Creatinine at initiation of CVVH (mg/dl) | 14/3.1
| 2.3/1.6
| 12/3.6
| 2.6/1.1
| 2.1/1.0
| 1.9/2.4
|
SOS onset post SCT (days)
| 10
| 6
| 7
| 11
| 19
| 20
|
Mechanical ventilation (MV) or O2 support
| MV
| MV
| O2
| O2
| MV
| MV
|
CVVH duration (days)
| 0.5
| 5
| 9
| 15
| 16
| 12
|
CVVH filter
| M60
| M60
| M60/M100
| M60
| M100
| M100
|
CVVH anticoagulation
| Heparin
| Citrate
| Citrate
| Citrate
| Citrate/
| Citrate/
|
Duration without clot (days)
| 0.5
| 3
| 4
| 5
| 4
| 6
|
Defibrotide
| No
| No
| Yes
| Yes
| Yes
| No
|
Outcome
| Died
| CR*
| CR
| CR
| Died
| CR
|
; BLS II – bare lymphocyte syndrome type II
* CR = US liver and serum bilirubin returned to normal;
CONCLUSIONS:
1. Early initiation of CVVH may be a useful modality to prevent progressive fluid overload and maintain electrolyte and acid base balance in patients with FO and AKI following SOS.
2. CVVH with citrate regional anticoagulation is safe and well tolerated in patients with SOS.