Open Journal of Nephrology, 2012, 2, 78-81 http://dx.doi.org/10.4236/ojneph.2012.24013 Published Online December 2012 (http://www.SciRP.org/journal/ojneph) Use of Continuous Venovenous Hemodiafiltration with a High Cutoff Membrane in a Patient with Severe Acute Pancreatitis Cosimo Chelazzi, Dario Giugni, Claudia Giannoni, Gianluca Villa, Angelo Raffaele De Gaudio Department of Critical Care, Anesthesiology and Intensive Care Section, University of Florence, Florence, Italy Email: cosimochelazzi@gmail.com Received October 30, 2012; revised November 30, 2012; accepted December 7, 2012 ABSTRACT In patients with severe acute pancreatitis (SAP) early and persistent elevated circulating levels of interleukins (IL)-1, 2 and 6 and tumor necrosis factor (TNF)-α are linked to severity of disease and early multiple organ failure (MOF), while persistently elevated serum IL-10 is linked to immune paralysis and infectious complications. Although experimental and clinical evidence exists that continuous venovenous hemodiafiltration with high cutoff membranes (HCO- CVVHDF) efficiently removes inflammatory mediators from blood of patients with severe sepsis or septic shock, data are lacking on the subset of patients with SAP, particularly in cases with uninfected necrosis. We treated with HCO- CVVHDF a 59-year-old man admitted to our intensive care unit (ICU) with SAP inducing early-onset cardiovascular, respiratory and renal dysfunctions associated with high circulating levels of IL-6 and TNF-α and without overt clinical or laboratory signs of infection. During the treatment, cardiovascular, respiratory and renal functions rapidly normalized and circulating levels of IL-6 and TNF-α consistently decreased. The patient was discharged from ICU on day 20. Keywords: Acute Pancreatitis; Multiple Organ Failure; Blood Purification 1. Introduction Severe acute pancreatitis (SAP) is an acute systemic in- flammatory disease with a poor prognosis in 7% - 15% of cases [1]. Early mortality is linked to multiple organ fail- ure (MOF), which is led by extended pancreatic necrosis and systemic inflammatory damage to organs, typically lungs and kidneys [2]. In patients with SAP, the systemic inflammatory response is driven mostly by high circulat- ing levels of IL-1, IL-6 and TNF-α. High levels of IL-6 are linked to severity of disease, early-onset multiple organ failure and increased mortality [2]. During the late phase of SAP, IL-10 may be predominant and lead to im- mune-paralysis and infectious complications, which are related to late-onset MOF and mortality [1]. We report our experience with a 59-year-old patient with SAP and early refractory MOF. Continuous venovenous hemodiafil- tration with a high cutoff membrane (HCO-CVVHDF) ef- fectively reversed severe on- going organ dysfunction. 2. Case Report A previously healthy 59-year-old man (83 kg, 170 cm) sought treatment at our hospital after suffering abdominal pain associated with nausea for three days. Laboratory tests suggested acute pancreatitis (white blood cell count, WBCC = 1.29 × 10 4 /L, serum amylase = 1248 U/L, total serum Ca 2+ = 6.0 mg/dl, procalcitonin (PCT) < 0.5 ng/ml). Variations over time of clinical and vital parameters are reported in Table 1. The first CT scan confirmed enlarge- ment of the pancreas without necrosis and showed ab- dominal fluid collections along the posterior abdominal wall. Upon diagnosis of acute pancreatitis, continuous infusion of gabexate-mesilate 1000 mg/day was started. The next day the patient was confused and complained of breathlessness. Hypoxia was evident (pH 7.28, PaO 2 68 mmHg spontaneously breathing with FiO 2 50%, PaCO 2 33 mmHg, BE-9.0, serum lactates 4.6 mmol/L). The tra- chea was intubated and mechanical ventilation started. He was subsequently transferred to our ICU. A new CT scan showed extended areas of pancreatic necrosis and fluid collections were evident around the gland, in the abdominal cavity and in the pleurae. On day 1, the pa- tient was febrile (38.7˚C), tachycardic and hypotensive (see Table 1). Clinical management followed recom- mendations on SAP care [3,4]. Aggressive fluid therapy was started to achieve a central venous pressure of at least 8 mmHg [3]. A continuous infusion of noradrena- line was needed, at an initial dose of 0.25 g/kg/min, to maintain a mean arterial pressure (MAP) of 65 mmHg. Urine output decreased to 0.48 ml/kg/h and serum creati- Copyright © 2012 SciRes. OJNeph