Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy

• Published in: American journal of health-system pharmacy Vol. 76; no. 11; pp. 810 - 813
• Main Authors: Branick, Kaitlin, Taylor, Matthew J, Trump, Matthew W, Wall, Geoffrey C
• Format: Journal Article
• Language: English
• Published: England Copyright American Society of Health-System Pharmacists, Inc. All rights reserved 17.05.2019
• Subjects: Acute Kidney Injury - etiology; Acute Kidney Injury - therapy; Amphotericin B - chemistry; Amphotericin B - pharmacology; Amphotericin B - therapeutic use; Area Under Curve; Blastomycosis - blood; Blastomycosis - complications; Blastomycosis - therapy; Combined Modality Therapy - methods; Continuous Renal Replacement Therapy; Critical Illness - therapy; Deoxycholic Acid - pharmacology; Deoxycholic Acid - therapeutic use; Drug Combinations; Drug Substitution; Equipment Failure; Extracorporeal Membrane Oxygenation - instrumentation; Humans; Male; Middle Aged; Oxygenators, Membrane - adverse effects; Respiratory Insufficiency - etiology; Respiratory Insufficiency - therapy; Treatment Outcome; extracorporeal membrane oxygenation; blastomycosis; continuous renal replacement therapy; liposomal amphotericin
• ISSN: 1079-2082; 1535-2900
• DOI: 10.1093/ajhp/zxz054

We describe the use of liposomal amphotericin B and amphotericin B deoxycholate in a critically ill patient with pulmonary blastomycosis receiving both venovenous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). A 50-year-old African American man presented for dyspnea and cough and was noted to have blastomycosis on bronchoscopy. He developed respiratory failure and acute kidney injury, requiring mechanical ventilation, ECMO, and CRRT. After 4 days of liposomal amphotericin, the transmembrane pressure gradient on the membrane oxygenator increased dramatically without visualization of a clot, requiring a circuit exchange. A trough amphotericin B level taken the day before the exchange was undetectable for amphotericin B. After the circuit exchange, the patient was switched to amphotericin B deoxycholate. A subsequent trough level was 3.8 μg/mL. The patient improved and was able to be decannulated. However, he did require tracheostomy and long-term hemodialysis. In our case we believe that liposomal amphotericin B was significantly removed by ECMO and was responsible for the failure of the ECMO circuit. We would suggest amphotericin B deoxycholate be used in such patients preferentially and that serum levels of the drug be assessed when possible.