Critical Care Science

Formerly Revista Brasileira de Terapia Intensiva

ISSN: 2965-2774

Free Online Access

Official Journal of the Associação de Medicina Intensiva Brasileira and the Sociedade Portuguesa de Cuidados Intensivos

 

2024 2024;35(4):413-415
LETTER TO THE EDITOR

10.5935/2965-2774.20230139-en

Capillary leak syndrome during continuous renal replacement therapy after renal hilum ligation in a hypercapnic landrace pig

Síndrome de extravasamento capilar durante terapia de substituição renal contínua após ligadura do hilo renal em suíno da raça Landrace com indução de hipercapnia

Yuri de Albuquerque Pessoa dos Santos1, Luis Carlos Maia Cardozo Júnior1, Pedro Vitale Mendes1, Bruno Adler Maccagnan Pinheiro Besen1, Marcelo Park,1

1 Universidade de São Paulo Faculdade de Medicina Intensive Care Unit, Hospital das Clínicas São Paulo SP Brazil Intensive Care Unit, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil

Conflicts of interest: None.

Responsible editor: Felipe Dal-Pizzol

Submitted on June 07, 2023
Accepted on June 08, 2023

Corresponding author: Marcelo Park, Unidade de Terapia Intensiva, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Enéas Carvalho de Aguiar, 255, Sala 11083, Zip code: 05403-000 - São Paulo (SP), Brazil, E-mail: marcelo.park@hc.fm.usp.br

 

Literature on dialysis in pigs is scarce, and there is no description of capillary leak syndrome during dialysis in pigs. Our aim in this paper is to bring attention to the possible occurrence of this syndrome, at least in the described specific condition.

In an ongoing experimental line of research, we are investigating the impact of high bicarbonate concentrations on blood pH during continuous venous-venous hemodialysis (CVVHD) in hypercapnic pigs with severe renal failure induced by hilum ligation.(1) In this described experiment, a female 31kg Landrace pig was used as the research subject. After anesthesia, a central venous line, venous dialysis catheter (12-French, 16cm, ArrowTM, PA, USA), Swan-Ganz catheter (Edwards LifesciencesTM, Irvine, USA), and an arterial line were inserted. After a median laparotomy, a cystostomy was performed (to ascertain anuria), and the renal hilum was ligated en bloc. The pig was stabilized for one hour after the end of the surgery. Then, the tidal volume was reduced to 2/3 (Table 1), and after one hour of tidal volume reduction, CVVHD was started.

Table 1 - Hemodynamic, respiratory and metabolic variables of the subject during the experiment
Baseline 15 minutes 30 minutes 45 minutes CVVHD 15 minutes 30 minutes 1 hour 2 hours 3 hours 4 hours
Hemodynamic
Heart rate (bpm) 85 94 122 109 111 94 99 119 153 211 220
ABPm (mmHg) 90 92 116 88 89 56 69 78 61 64 47
CVP (mmHg) 8 8 6 6 7 6 5 5 4 2 3
PAOP (mmHg) 10 12 10 10 9 10 6 5 4 13 17
PAPm (mmHg) 25 27 29 29 29 23 23 23 27 26 17
Lactate (mEq/L) 1,0 0.6 0.6 0.7 2.2
Norepinephrine
(mcg/kg/minute)
0 0 0 0 0 0 0 0.1 0.2 0.3 1.2
Respiratory
Tidal volume (mL) 240 160 160 160 160 160 160 160 160 200 240
Respiratory rate (IPM) 40 40 40 40 40 40 40 40 40 40 40
PEEP (cmH2O) 5 5 5 5 5 5 5 5 5 5 5
FiO2 (%) 21 40 40 40 40 40 40 30 30 25 25
PaO2 (mmHg) 71 101 75 73 83
PaCO2 (mmHg) 43 80 56 42 33
HCO3 (mEq/L) 22.7 23.7 20.3 17.6 14.8
SBE (mEq/L) -2.2 -4.8 -6.8 -8.4 -10.8
SatO2 (%) 93 95 94 88 93
Metabolic
Core temperature (°C) 36.3 37.2 37.5 37.6 37.5 36.1 36.1 36.2 36.4 36.3 36.8
pH 7.34 7.09 7.17 7.23 7.26
Glicemia (mg/dL) 102 116 130 127 283
Cai+2 (mMol/L) 1.31 1.39 1.31 1.32 1.36
K+ (mEq/L) 5 5.2 5.8 5.6 6.4
Na+ (mEq/L) 136 137 135 137 134
Cl- (mEq/L) 112 111 113 117 116
Blood flow (mL/minute) 0 0 0 0 0 205 207 209 212 211 209
Net ultrafiltration (mL) 0 0 0 0 0 11 26 53 74 87 143
Fluid intake* (mL) 0 0 0 0 0 0 250 250 500 800 1300
Fluid balance (mL) 0 0 0 0 0 -11 224 197 426 713 1157

CVVHD - continuous venous-venous hemodialysis; bpm - beats per minute; ABPm - mean systemic arterial blood pressure; CVP - central venous pressure; PAOP - pulmonary artery occlusion pressure; PAPm - mean pulmonary artery pressure; IPM - inspirations per minute; PEEP - positive end expiratory pressure; FiO2 - fraction of inspired oxygen; PaO2 - partial pressure of oxygen; PaCO2 - partial pressure of carbon dioxide; HCO3 - bicarbonate. SBE - base excess; SatO2 - oxygen saturation. Standard base excess and mcg/kg/minute denotes micrograms per kg per minute. From baseline to continuous venous-venous hemodialysis initiation, tidal volume was reduced to 2/3 of the baseline.

* Normal saline was used for fluid administration.

Table 1 - Hemodynamic, respiratory and metabolic variables of the subject during the experiment

In the first experiments, CVVHD was performed using the Fresenius F8® (Fresenius Medical CareTM, MA, USA) low-flow filter without the occurrence of any adverse events or complications.(1) Due to a shortage of this filter in the Brazilian market, we changed to an Elisio-H17® filter (Nipro Medical LTDATM, Sorocaba, São Paulo, Brazil). Surprisingly, in the first experiment using the new filter, fatal refractory shock, low cardiac output, and hemoconcentration occurred soon after continuous renal replacement therapy initiation. Figure 1 shows the change in hemoglobin and cardiac output during stabilization, hypoventilation and four hours of CVVHD. Table 1 shows the temporal evolution of other hemodynamic, respiratory, and metabolic variables during the experiment. Hemoconcentration and the dramatic fall in cardiac output occurred at the same time as the subject exhibited severe tachycardia, high norepinephrine levels, and a need for normal saline. We also observed a decrease in central venous pressure and mean pulmonary artery pressure despite a terminal rise in pulmonary artery occlusion pressure. The terminal paradoxical behavior of the low mean pulmonary artery pressure and high pulmonary artery occlusion pressure could be explained by the association of hypovolemia with left ventricle dysfunction.

Figure 1 - Change in hemoglobin and cardiac output during the five hours of the experiment.

The hemoconcentration with the associated severe hypovolemic hemodynamic behavior in this case is very similar to the capillary leak syndrome as described by Dr. Bayard Clarkson, which may occur with extracorporeal support systems.(2-4) Many pathophysiological pathways are linked to capillary leak syndrome, which is a condition that is associated with a high mortality.(2) In advanced phases, severe myocardial depression can occur, similar to what occurred in our experiment.(5) In later experiments, we tried additional filters, such as Diacap Acute L® (BBraunTM, São Gonçalo, Rio de Janeiro, Brazil), Poliflux® (GambroTM, São Paulo, Brazil), and Fx80® (Fresenius Kabi Brazil LTDATM, Itapecerica da Serra, São Paulo, Brazil), without any systemic reaction of the subject.

This paper demonstrates that capillary leak syndrome may occur in experiments that are conducted using extracorporeal systems. This phenomenon is something that translational researchers should be aware of to help with the appropriate choice of dialyzers in pigs.

ACKNOWLEDGEMENT

The experiment was funded by the Emergency discipline of the Faculdade de Medicina da Universidade de São Paulo.

REFERENCES

Romano TG, Azevedo LC, Mendes PV, Costa EL, Park M. Effect of continuous dialysis on blood pH in acidemic hypercapnic animals with severe acute kidney injury: a randomized experimental study comparing high vs. low bicarbonate affluent. Intensive Care Med Exp. 2017;5(1):28.
Gousseff M, Arnaud L, Lambert M, Hot A, Hamidou M, Duhaut P, Papo T, Soubrier M, Ruivard M, Malizia G, Tieulié N, Rivière S, Ninet J, Hatron PY, Amoura Z; Capillary Leak Syndrome Registry. The systemic capillary leak syndrome: a case series of 28 patients from a European registry. Ann Intern Med. 2011;154(7):464-71.
Clarkson B, Thompson D, Horwith M, Luckey EH. Cyclical edema and shock due to increased capillary permeability. Am J Med. 1960;29(2):193-216.
Hamada Y, Kawachi K, Tsunooka N, Nakamura Y, Takano S, Imagawa H. Capillary leakage in cardiac surgery with cardiopulmonary bypass. Asian Cardiovasc Thorac Ann. 2004;12(3):193-7.
Garatti L, Wu MA, Ammirati E, Sacco A. Systemic leak capillary syndrome with myocardial involvement and cardiogenic shock: a case report. Eur Heart J Case Rep. 2022;6(7):ytac262.
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