Saturday, April 5, 2014

Plasma exchange for central pontine myelinolysis?

As we know that a complication of overcorrection of hyponatremia is central pontine myelinolysis(CPM). Once it happens, what can be done to improve the neurological complications?

A recent case report shines light into an older treatment approach from 1990s- plasma exchange. In this case report, a patient received IV bicarbonate therapy for distal RTA from sjorgen’s syndrome and Na corrected from 140s to 170s in 24 hours and then few days later leads to CPM .
Two days of 4+ liters of plasma exchange were done with albumin and FFP replacement. Two days following the treatment, the neurological symptoms improved.  The sodium level also was getting staying stable.

So how does one treat CPM? – besides preventive strategies

There have been some animal  studies investigating the benefits of re-inducing hyponatremia in the case of rapid  overcorrection of hyponatremia in order to avoid osmotic demyelination. So bring the Na back down again to allow for the change to be mitigated.  What about plasma exchange? This was first attempted in 1999 Lancet paper that showed that 3 patients were successfully treated with plasma exchange ( but in those cases were for weeks compared to the above case for only 2 sessions)

Another case report exists in use of this strategy in a liver transplant patient with CPM.
One more in the neurology literature  adds to this potential treatment.
 Myelin toxic compounds may be removed by plasma exchange due to their high molecular weight and preventing the further damage is the suggested mechanism.

Would it be worth doing plasma exchange while correcting for hyponatremia simultaneously in high risk patients? – such as the alcoholic beer potemanias? Some food for thought.

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