title: The hemophagocytic syndrome: titrating continuous hemofiltration to the degree of lactic acidosis.
abstract: In 3 cases of severe multiple organ failure due to hemophagocytic lymphohistiocytosis (HLH) in children, the authors demonstrate the utility of continuous hemofiltration in attenuating the consequences of excess cytokine activity, with therapy titrated to the degree of lactic acidosis. HLH was diagnosed in 3 encephalopathic children with multiple organ failure, elevated ferritin (49,396-237,582 pmol/L; or 21,983-105,733 ng/mL), elevated serum triglyceride, and depressed cell lines. One had a known malignancy, one had EBV-associated lymphoproliferative disease, and one was previously healthy. Continuous hemofiltration was initiated, with the ultrafiltrate production rate and countercurrent dialysate flow titrated to metabolic acidosis as reflected by the serum lactate (maximum 3.5 mmol/L or 31.6 mg/dL). Hemofiltration was titrated upward until lactic acidosis resolved, through clearance of lactate or interruption of excess cytokine-driven activity; maximum prescription was 2000 mL/h ultrafiltrate production plus 2500 mL/h dialysate flow. Stability was achieved with hemofiltration, then substantial resolution occurred with treatment according to the HLH-94 protocol (dexamethasone, cyclosporin, VP-16, intrathecal methotrexate). One child succumbed to candidiasis. Another made a full recovery. A third succumbed to his primary malignancy. HLH should be suspected in unexplained or unresolving multiple organ failure. Titration of hemofiltration based on measurable parameters of cellular metabolism (e.g., lactate, base deficit) may stabilize the child with metabolic acidosis long enough to allow proper diagnosis and institution of definitive therapy. Hemofiltration is not a panacea but rather a stabilizing mechanism, with poorly understood effects on interstitial water and solute flux, that facilitates recovery over weeks, not days.
authors.affiliation: Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, California 94304, USA. jdicarlo@stanford.edu
authors.forename: Joseph
authors.initials: J
authors.lastname: DiCarlo
authors.forename: Wendy Y S
authors.initials: WY
authors.lastname: Lui
authors.forename: Lorry
authors.initials: L
authors.lastname: Frankel
authors.forename: William
authors.initials: W
authors.lastname: Howell
authors.forename: Joshua
authors.initials: J
authors.lastname: Schiffman
authors.forename: Steven
authors.initials: S
authors.lastname: Alexander
mesh_terms: D000140:Acidosis, Lactic / Q000628:therapy*; D002648:Child; D016207:Cytokines / Q000096:biosynthesis; D006440:Hemofiltration; D006801:Humans; D051359:Lymphohistiocytosis, Hemophagocytic / Q000150:complications / Q000628:therapy*; D008297:Male; D008657:Metabolic Clearance Rate; D009102:Multiple Organ Failure / Q000209:etiology
chemical_list: D016207:Cytokines