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Unexplained Hemolysis in a Transplant Patient on Extracorporeal Membrane Oxygenation Support FREE TO VIEW

Aida Venado, MD; Pilar Acosta Lara, MD; Keith Wille, MD; Scott Bellot, MD; Enrique Diaz-Guzman, MD
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University of Alabama at Birmingham, Birmingham, AL

Chest. 2014;146(4_MeetingAbstracts):346A. doi:10.1378/chest.1991961
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SESSION TITLE: Miscellaneous Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemolysis is a complication of extracorporeal membrane oxygenation (ECMO) support associated with poor outcomes. We present a case of severe hypertriglyceridemia causing spurious hemolysis in a lung transplant patient on ECMO.

CASE PRESENTATION: A 20-year-old man who developed bronchiolitis obliterans thirty-three months after bilateral lung transplantation presented with refractory hypercapnic respiratory failure. Veno-venous ECMO was started as a bridge to retransplantation. Four days later he was ambulating with ECMO and mechanical ventilation support. Sirolimus was added to his immunossupressive regimen including mofetil mycophenolate, prednisone, and cyclosporine. Fourteen days after the addition of sirolimus 1 mg daily a progressive increase in plasma-free hemoglobin was noted, with peak level of 560 mg/dl. Haptoglobin and total bilirubin levels were normal (73 mg/dl and 1.3 mg/dl, respectively). LDH level was 385 mg/dl. His blood sample appeared turbid and his lipid profile was markedly abnormal: triglyceride level, 830 mg/dl; total cholesterol level, 210 mg/dl; HDL level, 28 mg/dl; and LDL level, 109 mg/dl. A plasma sample was sent to a specialized laboratory where it was analyzed spectrophotometrically at 8 wavelengths ranging from 415 nm to 700 nm, yielding a free hemoglobin level of 55.6 mg/dl. Patient underwent plasmapheresis and fenofibrate treatment with rapid decline in triglyeride level and simultaneous decrease in plasma free hemoglobin.

DISCUSSION: Plasma free hemoglobin concentration is closely monitored during ECMO as a measure of hemolysis. Triglycerides confer turbidity and scatter the light, falsely raising the baseline absorbance of a sample. Hypertriglyceridemia interferes with the measurement of plasma free hemoglobin causing spurious hemolysis. Filtering turbid samples is recommended to minimize interference. Plasmapheresis is effective in rapidly reducing triglyceride levels and has been used for sirolimus-induced hypertriglyceridemia in lung transplant patients.

CONCLUSIONS: Spurious hemolysis during ECMO should be suspected when plasma free hemoglobin elevation does not correlate with haptoglobin, LDH and bilirubin levels. Clinicians should be aware of the effect of hypertriglyceridemia causing spurious hemolysis.

Reference #1: Fernandez-Bussy S, Akindipe O, Baz M, et al. Sirolimus-induced severe hypertriglyceridemia in a lung transplant recipient. Transplantation. 2010 Feb 27;89(4):481-2

Reference #2: Kroll MH, Elin RJ. Interference with Clinical Laboratory Analyses. Clin. Chem Vol. 40, No. 11, 1994

DISCLOSURE: The following authors have nothing to disclose: Aida Venado, Pilar Acosta Lara, Keith Wille, Scott Bellot, Enrique Diaz-Guzman

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