pmjТихоокеанский медицинский журналPacific Medical Journal1609-1175TGMU10.34215/1609-1175-2026-2-86-89pmj-3149Research ArticleНАБЛЮДЕНИЯ ИЗ ПРАКТИКИPRACTICE OBSERVATIONSЭтапная стратегия экстракорпоральной поддержки при внебольничной пневмонии, осложненной сепсисом и полиорганной недостаточностью (клиническое наблюдение)Multistep extracorporeal support strategy for community-acquired pneumonia complicated by sepsis and multiple organ failure (A clinical case)ЯровенкоС. С.YarovenkoS. S.

Владивосток

Vladivostok

https://orcid.org/0000-0001-8343-2981КнязенкоП. А.KnyazenkoP. A.

Князенко Павел Александрович – заместитель главного врача по анестезиологии-реаниматологии.

Владивосток, ул. Садовая, 22

Pavel A. Knyazenko - Deputy Chief Physician for Anesthesiology and Intensive Care.

22 Sadovaya str., Vladivostok

pknyazenko@mail.ruПаветьевИ. А.PavetievI. A.

Владивосток

Vladivostok

МинаковаЕ. Ю.MinakovaE. Yu.

Владивосток

Vladivostok

НевзороваВ. А.NevzorovaV. A.

Vladivostok

МаркеловаЕ. В.MarkelovaE. V.

Владивосток

Vladivostok

Владивостокская клиническая больница № 1РоссияVladivostok Clinical Hospital No. 1Russian FederationТихоокеанский государственный медицинский университетРоссияPacific State Medical UniversityRussian Federation202619072026028689Copyright © Яровенко С.С., Князенко П.А., Паветьев И.А., Минакова Е.Ю., Невзорова В.А., Маркелова Е.В., 20262026Яровенко С.С., Князенко П.А., Паветьев И.А., Минакова Е.Ю., Невзорова В.А., Маркелова Е.В.Yarovenko S.S., Knyazenko P.A., Pavetiev I.A., Minakova E.Y., Nevzorova V.A., Markelova E.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.tmj-vgmu.ru/jour/article/view/3149

Представлено клиническое наблюдение пациента 49 лет с внебольничной тяжелой двусторонней полисегментарной пневмонией, осложненной сепсисом и полиорганной недостаточностью (СПОН): острое повреждение почек (ОПП) с олигоанурией, выраженная гипербилирубинемия, тромбоцитопения с подозрением на тромботическую микроангиопатию (ТМА). Цель – показать тактику дифференциальной диагностики ТМА при тяжелой пневмонии и последовательное применение экстракорпоральных методов лечения (ЭМЛ). Тяжесть оценивали по шкале SOFA. Заместительная почечная терапия (ЗПТ) – в режиме непрерывного вено-венозного гемодиализа (ПВВГД) тремя интервалами. Терапевтический плазмообмен (ТПО) – два сеанса по 2 объема циркулирующей плазмы. До ЭМЛ выполнен забор крови на активность ADAMTS13. На фоне комплексной терапии с ПВВГД и ТПО отмечено снижение SOFA с 12 до 7 баллов, рост тромбоцитов с 30 × 10⁹/л до 187 × 10⁹/л, снижение билирубина с 559,6 до 16,6 мкмоль/л, восстановление диуреза. Активность ADAMTS13 – 19%, что при сепсисе требует дополнительной интерпретации. Случай подчеркивает важность ранней диагностики ТМА, забора крови на ADAMTS13 до ЭМЛ и эффективность раннего применения плазмообмена.

This article presents a clinical case report of a 49-year-old male patient with severe community-acquired bilateral polysegmental pneumonia, complicated by sepsis and multiple organ failure including acute kidney injury (AKI) with oliguria, severe hyperbilirubinemia, and thrombocytopenia with suspected thrombotic microangiopathy (TMA). Objective: To demonstrate strategies for the differential diagnosis of TMA in severe pneumonia and the sequential use of extracorporeal therapies (ECT). Severity was assessed using the SOFA score. Renal replacement therapy (RRT) was performed as continuous veno-venous hemofiltration (CVVH) in three intervals. Therapeutic plasma exchange (TPE) consisted of two sessions, each involving two volumes of circulating plasma. Prior to ECT, a blood sample was collected to measure ADAMTS13 activity. In the context of complex therapy involving CVVH and TPE, the SOFA score decreased from 12 to 7 points. Additionally, the platelet count increased from 30 × 10⁹/L to 187 × 10⁹/L, bilirubin levels decreased from 559.6 to 16.6 μmol/L, and diuresis was restored. However, ADAMTS13 activity was only 19%, which requires further interpretation considering the presence of sepsis. This case highlights the importance of early TMA diagnosis, ADAMTS13 blood testing before ECT, and the effectiveness of early plasmapherapy.

сепсисполиорганная недостаточностьострое повреждение почекПВВГДплазмообментромботическая микроангиопатияsepsismultiple organ failureacute kidney injurycontinuous veno-venous hemofiltrationplasma exchangethrombotic microangiopathyавторы заявляют о финансировании работы из собственных средствReferencesSinger M, Deutschman CS, Seymour CW, Shankar-Hari M, Annan R, Bernard GR, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi: 10.1001/jama.2016.0287Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annan R, Bernard GR, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi: 10.1001/jama.2016.0287Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):1974–1982. doi: 10.1097/CCM.0000000000005357Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):1974–1982. doi: 10.1097/CCM.0000000000005357Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2(1):1–138. doi: 10.1038/kisup.2012.1Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2(1):1–138. doi: 10.1038/kisup.2012.1Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019;155(3):626–638. doi: 10.1016/j.chest.2018.09.004Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019;155(3):626–638. doi: 10.1016/j.chest.2018.09.004Pène F, Russell L, Aubron C. Thrombocytopenia in the intensive care unit: diagnosis and management. Ann Intensive Care. 2025;15(1):25. doi: 10.1186/s13613-025-01447-xPène F, Russell L, Aubron C. Thrombocytopenia in the intensive care unit: diagnosis and management. Ann Intensive Care. 2025;15(1):25. doi: 10.1186/s13613-025-01447-xIba T, Levy JH, Wada H, Thachil J, Warkentin TE, Levi M. Subcommittee on Disseminated Intravascular Coagulation. Differential diagnoses for sepsis-induced disseminated intravascular coagulation: communication from the SSC of the ISTH. J Thromb Haemost. 2019;17(2):415–419. doi: 10.1111/jth.14354Iba T, Levy JH, Wada H, Thachil J, Warkentin TE, Levi M. Subcommittee on Disseminated Intravascular Coagulation. Differential diagnoses for sepsis-induced disseminated intravascular coagulation: communication from the SSC of the ISTH. J Thromb Haemost. 2019;17(2):415–419. doi: 10.1111/jth.14354George JN, Nester CM. Syndromes of thrombotic microangiopathy. N Engl J Med. 2014;371(7):654–666. doi: 10.1056/NEJMra1312353George JN, Nester CM. Syndromes of thrombotic microangiopathy. N Engl J Med. 2014;371(7):654–666. doi: 10.1056/NEJMra1312353Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2486–2495. doi: 10.1111/jth.15006Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2486–2495. doi: 10.1111/jth.15006Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2496–2502. doi: 10.1111/jth.15010Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2496–2502. doi: 10.1111/jth.15010Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, et al. A British society for haematology guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol. 2023;203(4):546–563. doi: 10.1111/bjh.19026Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, et al. A British society for haematology guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol. 2023;203(4):546–563. doi: 10.1111/bjh.19026Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, et al. Guidelines on the use of therapeutic apheresis in clinical practice – evidence-based approach from the writing committee of the american society for apheresis: The eighth special issue. J Clin Apher. 2019;34(3):171–354. doi: 10.1002/jca.21705Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, et al. Guidelines on the use of therapeutic apheresis in clinical practice – evidence-based approach from the writing committee of the american society for apheresis: The eighth special issue. J Clin Apher. 2019;34(3):171–354. doi: 10.1002/jca.21705Singh K, Kwong AC, Madarati H, Kunasekaran S, Sparring T, Fox-Robichaud AE, et al. Characterization of ADAMTS13 and von Willebrand factor levels in septic and non-septic ICU patients. PLoS One. 2021;16(2):e0247017. doi: 10.1371/journal.pone.0247017Singh K, Kwong AC, Madarati H, Kunasekaran S, Sparring T, Fox-Robichaud AE, et al. Characterization of ADAMTS13 and von Willebrand factor levels in septic and non-septic ICU patients. PLoS One. 2021;16(2):e0247017. doi: 10.1371/journal.pone.0247017Lin J-J, Chan O-W, Hsiao H-J, Wang Y, Hsia S-H, Chiu C-H. Decreased ADAMTS 13 Activity is Associated With Disease Severity and Outcome in Pediatric Severe Sepsis. Medicine (Baltimore). 2016;95(16):e3374. doi: 10.1097/MD.0000000000003374Lin J-J, Chan O-W, Hsiao H-J, Wang Y, Hsia S-H, Chiu C-H. Decreased ADAMTS 13 Activity is Associated With Disease Severity and Outcome in Pediatric Severe Sepsis. Medicine (Baltimore). 2016;95(16):e3374. doi: 10.1097/MD.0000000000003374

The authors declare that there are no conflicts of interest present.