Combined extracorporeal CO2 removal and renal replacement therapy in a pregnant patient with COVID-19: a case report

Abstract

Background. Pregnant women are at high risk of Coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome. Currently, one of the cornerstones in the treatment of this condition is lung-protective ventilation (LPV) with low tidal volumes. However, the occurrence of hypercapnia may limit this ventilatory strategy. So, different extracorporeal CO2 removal (ECCO2R) procedures have been developed. ECCO2R comprises a variety of techniques, including low-flow and high-flow systems, that may be performed with dedicated devices or combined with continuous renal replacement therapy (CRRT).
Case description. Here, we report a unique case of a pregnant patient affected by COVID-19 who required extracorporeal support for multiorgan failure. While on LPV, because of the concomitant hypercapnia and acute kidney injury, the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a CRRT platform. This combined treatment reducing hypercapnia allowed LPV maintenance at the same time while providing kidney replacement and ensuring maternal and fetal hemodynamic stability. Adverse effects consisted of minor bleeding episodes due to the anticoagulation required to maintain the extracorporeal circuit patency. The patient’s pulmonary and kidney function progressively recovered, permitting the withdrawal of any extracorporeal treatment. At the 25th gestational week, the patient underwent spontaneous premature vaginal delivery because of placental abruption. She gave birth to an 800-gram female baby, who three days later died because of multiorgan failure related to extreme prematurity.
Conclusions. This case supports using ECCO2R-CRRT combined treatment as a suitable approach in the management of complex conditions, such as pregnancy, even in the case of severe COVID-19.

Keywords: pregnancy, COVID-19, lung-protective ventilation, hypercapnia, CO2 removal, acute kidney injury, continuous renal replacement therapy

Introduction

Pulmonary involvement in Coronavirus disease 2019 (COVID-19) is highly heterogeneous, with clinical presentation ranging from asymptomatic forms to acute respiratory distress syndrome (ARDS) [1]. This heterogenicity may be explained by demographic factors, history of comorbidities, distinctive genetic background, and pharmacological treatments [2].

Among the different populations of COVID-19 patients, pregnant women deserve specific attention. Indeed, these patients, due to immunological and cardiorespiratory changes occurring in pregnancy, are at risk of the more severe complications of the disease, including ARDS [3, 4].

Most patients with ARDS require mechanical ventilation (MV), and in some cases also extracorporeal respiratory support (ECLS) [5].

These therapies encompass extracorporeal membrane oxygenation (ECMO) and the extracorporeal carbon dioxide removal system (ECCO2R). Briefly, ECMO takes over the gas exchange function of the lungs ensuring full oxygenation and CO2 removal, while ECCO2R is a CO2 removal system that does not affect oxygenation, and whose principal aim is consenting to lung protection (Table 1). 

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HELLP syndrome and hemolytic uremic syndrome during pregnancy: two disease entities, same causation. Case report and literature review

Abstract

Abstract

Thrombotic microangiopathies (TMA) are a group of diseases that can complicate pregnancy and threaten the lives of both the mother and the fetus. Several conditions can lead to TMA, including thrombotic thrombocytopenic purpura (TTP), HELLP syndrome and hemolytic uremic syndrome (HUS). We describe the case of a 39-year-old woman who presented a HELLP syndrome in the immediate postpartum period. The patient had acute kidney injury (AKI), increased LDH, unmeasurable haptoglobin levels and hypocomplementemia. Her ADAMTS13 value was normal, thus ruling out TTP. Shiga toxin tests were negative, so HUS associated with E. coli was also ruled out. HELLP syndrome and atypical hemolytic-uremic syndrome (aHUS) remained the most probable diagnosis. In the days following childbirth, the patient’s transaminase and bilirubin levels normalized while the anemia persisted, as did the AKI, resulting in the institution of dialysis treatment. A diagnosis of aHUS was made and therapy with eculizumab was started. The patient’s blood counts progressively improved, urine output was restored, her indices of renal function also concomitantly improved and dialysis was interrupted. A rash appeared after the third administration of eculizumab and the treatment was suspended. The patient is currently being followed up and has not relapsed. At thirteen months after delivery her renal function is normal as are her platelet counts, LDH, haptoglobin levels and proteinuria. Tests for mutations in the genes that regulate complement activity were negative. We believe that childbirth triggered the HELLP syndrome, which in turn brought about and sustained the HUS. In fact, the patient’s liver function improved right after delivery, while her kidney injury and hemolysis persisted, and she also had an excellent response to eculizumab. To our knowledge, no other cases of HELLP syndrome associated with haemolytic uremic syndrome during pregnancy have been reported in literature, nor have cases in which treatment with eculizumab was limited to only three administrations.

Keywords: HELLP syndrome, hemolytic uremic syndrome, pregnancy, eculizumab, thrombotic microangiopathy

Sorry, this entry is only available in Italian.

Introduzione

Le microangiopatie trombotiche (MAT) rappresentano un eterogeneo gruppo di affezioni che possono complicare la gravidanza mettendo a rischio la vita della madre e del feto. Tra di esse troviamo la porpora trombotica trombocitopenica (PTT), la sindrome HELLP e la sindrome emolitica uremica (SEU), tutte caratterizzate da un danno a carico delle cellule endoteliali e trombosi dei piccoli vasi che si manifestano clinicamente con anemia emolitica, trombocitopenia, e danno d’organo [13]. I confini tra queste patologie non sono ben definiti tanto che può essere difficile o addirittura impossibile una diagnosi differenziale, considerando poi che dette condizioni possono coesistere [48]. A complicare ulteriormente l’iter diagnostico, durante la gravidanza i parametri ematologici [9], della proteinuria [10] e della concentrazione del complemento hanno range di riferimento differenti rispetto al soggetto non in gravidanza [11-12]. 

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Minimal Change Relapse During Pregnancy

Abstract

The appearance of nephrotic syndrome during pregnancy is considered an exceptional event, whose incidence is around 0.012-0.025% of all pregnancies, and it is even more rare when the cause is represented by minimal lesions glomerulonephritis. In this article we will describe the case of a patient with a histological diagnosis of glomerulonephritis with minimal lesions, tending to frequent relapses. She was in complete remission since 2013 after treatment with cyclosporine. suspended in May 2017. After few weeks she become pregnant, and the pregnancy was regular until the 23rd week. when a recurrence of nephrotic syndrome appears. She was treated with steroids bolus followed by oral steroid, and afterwards gave birth to a live fetus with spontaneous delivery at 37 weeksThe few data in the literature confirm that recurrence of glomerulonephritis due to minimal lesions in pregnancy should be treated rapidly with steroids, that can induce rapid remission and protect both the pregnant than the fetus from even serious damage.

Keywords: Minimal change nephropathy, pregnancy, nephrotic syndrome, steroid.

Sorry, this entry is only available in Italian.

INTRODUZIONE

La glomerulonefrite a lesioni minime è definita dalla normalità dei glomeruli all’esame in microscopia ottica, e dalla presenza all’esame ultrastrutturale glomerulare della fusione dei pedicelli dei podociti. La glomerulonefrite a lesioni minime si caratterizza per la presenza di proteinuria e per la sensibilità all’uso di steroidi.

 

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