Use of Slow Low-Efficiency Dialysis in a Patient With Status Epilepticus Secondary to Herpes Simplex Encephalitis With Severe Acute Kidney Injury.

Abstract

Introduction: Acute kidney injury (AKI) in the critical care unit is an independent risk factor for poor outcomes such as mortality. In patients with acute neurological injury and severe AKI, the timing and renal replacement therapy (RRT) modifications must be considered. Sustained low-efficiency dialysis (SLED) is a cost-effective alternative to continuous renal replacement therapy (CRRT) in critically ill AKI patients. We present a case of a 43-year-old male diagnosed with status epilepticus secondary to herpes simplex virus Type 1 (HSV-1) central nervous system (CNS) infection who developed severe AKI and underwent SLED.

Case presentation: We present a case of a 43-year-old male, hypertensive, with no known chronic kidney disease (CKD) who was referred to nephrology service for management of AKI. He was being managed as a case of status epilepticus secondary to CNS infection. Diagnostic tests revealed elevated creatinine at 3.72 mg/dL from 0.9 mg/dL. Blood urea nitrogen was at 39 mg/dL. Sodium was at 148 mEq/L, and potassium at 3.4 mEq/L. Urinalysis had trace protein, moderate blood, and red blood cells at 12 cells per high power field (hpf). Creatine kinase MM (CK-MM) was at 514 U/L (2.2x ULN). The patient also had marginal urine output at 0.2-0.4 mL/kg/h with the patient weighing 86 kg. Although the patient had Stage 3 AKI, RRT was initiated as a supportive measure. He underwent SLED for 6 hours with net ultrafiltration at 0 mL. Urine output gradually improved from 0.9 to 1.3 mL/kg/h. Repeat creatinine taken 2 days after showed a decreasing trend to 2.68 mg/dL. Seizures were controlled with midazolam drip, valproic acid, and lacosamide. Renal parameters were continuously monitored, and continuation of renal replacement was not deemed necessary. During his stay at the neurocritical care unit, lumbar puncture was performed, and cerebrospinal fluid tested positive for HSV-1. Appropriate antimicrobials and methylprednisolone pulse therapy 1 g intravenously for 5 days were given. Neurologic status improved with a Glasgow coma scale of 11T (E4VTM6). Renal parameters were serially monitored, with repeat creatinine prior to discharge at 0.6 mg/dL.

Conclusion: SLED can be used as a treatment modality in a neurocritically ill patient with status epilepticus for solute clearance. Good clinical judgment, early recognition, and ability to individualize care with management of AKI in the critical care unit can help improve clinical outcomes.