Patchy renal vasoconstriction in rhabdomyolysis-related acute renal failure

In rhabdomyolysis-related acute renal failure evidence of patchy renal vasoconstriction during the recovery phase was obtained by abdominal CT scan, which showed a wedge-shaped high-density area in the kidney.

Chronic alcoholic proximal wasting: physiological, morphological and biochemical studies in skeletal muscle

Electromyography, muscle histochemistry and assay of all glycolytic enzymes, phosphorylase, glycogen, carnitine and several mitochondrial marker enzymes in skeletal muscle (vastus lateralis) were carried out in two groups. One group comprised chronic alcoholic patients with prominent proximal wasting, the other was an alcoholic group with normal neuromuscular examination. Biochemical results were compared with data from control groups with normal muscle histology and with non-alcohol related type 2b fibre atrophy. Either 2b atrophy factor or 2b variability coefficient were increased in all wasted alcoholic patients, with normal values in alcoholics without wasting. Electromyography studies were usually normal in proximal muscles, although several patients had mild distal neuropathies. A significant fall in activity of phosphorylase and all glycolytic enzymes was found in wasted alcoholics with reference to normal controls. In the non-ethanolic 2b atrophy group the activity of several glycolytic enzymes was also significantly lower, but for each enzyme the mean activity was not depressed to the same extent as in the wasted alcoholic group. Muscle glycogen, carnitine, and mitochondrial marker enzyme activities (isocitrate dehydrogenase, monoamine oxidase, cytochrome oxidase) were normal in alcoholics with proximal wasting. It is concluded that there is no deficiency of mitochondrial marker enzymes in wasted alcoholics and that a significant depression in glycogenolytic and glycolytic enzyme activity is seen which is explained in part, but probably not fully, by 2b fibre atrophy.

ECG abnormalities in myoglobinuria: review of the literature

Reports of electrocardiographic abnormalities in association with myoglobinuria have been sparse and have included conduction disturbances, ST segment shifts, and T-wave changes. In many instances, these changes were noted in patients with underlying heart disease. We report a case of a 34-year-old woman with ST segment depression and T-wave inversion in the inferolateral leads during the acute episode of myoglobinuria. There was no demonstrable underlying heart disease, and there was parallel resolution of these ECG changes with myoglobinuria. We conclude that these ECG changes were produced by cardiac muscle involvement in a manner similar to that observed in skeletal muscle in myoglobinuria.

Theophylline-induced protection in myoglobinuric acute renal failure: further characterization

We have reported previously that aminophylline has an ameliorating effect on the course and severity of glycerol-induced myoglobinuric acute renal failure in rats. Since aminophylline dissociates into theophylline in biological fluids and since theophylline is an adenosine receptor antagonist, we attributed the ameliorating effects to antagonism of the hemodynamic effects of endogenous adenosine. However, theophylline blocks tubuloglomerular feedback and produces natriuresis, and either of these effects might have accounted for the beneficial effects in acute renal failure. Therefore, this study was designed to further characterize the effects of theophylline in glycerol-induced acute renal failure in rats. Aminophylline had dose-dependent beneficial effects, as judged by the peak serum creatinine during the 3 days following induction of acute renal failure, by the number of animals with peak serum creatinine greater than 1 mg/dL, and by the mortality rate. Both furosemide and theophylline block tubuloglomerular feedback and produce natriuresis, but aminophylline had protective effects, whereas furosemide actually increased mortality, compared with aminophylline, following induction of myoglobinuric acute renal failure. Therefore, aminophylline's protective effects are independent of tubuloglomerular feedback and natriuresis. These results offer further support for the hypothesis that adenosine-induced hemodynamic changes play a pathogenic role in glycerol-induced acute renal failure in rats.

Nontraumatic rhabdomyolysis and acute renal failure

Four cases of acute renal failure occurring in association with unusual causes of nontraumatic rhabdomyolysis are reported. Three of the four were associated with drug overdoses.

Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure

Patients with rhabdomyolysis (RBD) and acute renal failure (ARF) are hypocalcemic during the oliguric phase of ARF and over 30% develop hypercalcemia during the diuretic phase. The present study examined the factors underlying these derangements in calcium metabolism in 15 patients: 7 with RBD and ARF, 4 with RBD only, and 4 with ARF only. All patients had hypocalcemia on admission and the hypocalcemia was more pronounced in those with RBD and ARF. All patients with RBD independent of the presence or absence of ARF had calcium deposition in soft tissues as documented by technetium-99 scan. In 4 patients with RBD and ARF, hypercalcemia developed during the diuretic phase at a time when Serum PTH levels were undetectable. Only patients with RBD and ARF had a significant increase in serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D [1,25(OH)2D] during the diuretic phase and both the increments in and the levels of 1,25(OH)2D were significantly greater in those who were hypercalcemic. The data indicate that 1) hypocalcemia occurs in RBD independent of ARF and is most likely related to calcium deposition in injured tissues, and 2) elevation in serum levels of 1,25(OH)2D plays an important role in the genesis of hypercalcemia during the diuretic phase of patients with RBD and ARF. Our observations suggest that extrarenal production of 1,25(OH)2D may occur in these patients, and/or that the renal production of 1,25(OH)2D may not be so tightly controlled as it is in normal subjects.

Rhabdomyolysis and acute renal failure in chronic alcoholics with myopathy, unrelated to acute alcohol ingestion

Rhabdomyolysis leading to acute renal failure necessitating hemodialysis is described in three chronic alcoholics. In each case an acute medical or surgical event, but not alcoholic intoxication, was implicated. Renal biopsies demonstrated acute tubular necrosis with intraluminal deposits consisting of Tamm-Horsfall protein and myoglobin. After recovery all three patients were demonstrated to have proximal muscle weakness with similar electromyographic abnormalities but nerve-conduction was impaired in only two. Muscle biopsies showed mixed, but predominantly type II fiber atrophy and reduced muscle phosphorylase levels. In the one patient tested the lactate response to forearm muscle ischemia was abnormal. It is postulated that chronic alcoholics may be predisposed to rhabdomyolysis and acute renal failure following acute medical and surgical stress as well as acute alcohol abuse. The muscle damage in these patients may be due to impaired intra cellular glycogen metabolism.

Neuroleptic malignant syndrome and dopaminergic blockade

After receiving 90 mg of haloperidol and 100 mg of chlorpromazine hydrochloride within 25 hours, a 29-year-old man was found to have neuroleptic malignant syndrome (NMS), characterized by the acute onset of hyperpyrexia, extreme muscular rigidity, autonomic instability, and coma. Subsequently, rhabdomyolysis developed, with myoglobinuric renal failure and bilateral anterior tibial compartment syndromes. The patient's initial neuroleptic levels were in the therapeutic and nontoxic ranges. He was treated with supportive measures and his clinical improvement was paralleled by decreased neuroleptic levels, a return toward normal of an elevated prolactin level, and an increased responsiveness to a dopamine hydrochloride infusion. This supports an association between NMS and dopamine receptor blockade.

Prevention of acute renal failure in traumatic rhabdomyolysis

Following the collapse of a building, seven subjects (aged 18 to 41 years) were released from under the rubble within one to 28 hours. All seven suffered from extensive crush injuries with evidence of severe rhabdomyolysis and were treated by the induction of an alkaline solute diuresis immediately on their extrication from the debris. The leakage of muscle constitutents was estimated by quantifying the net total body potassium losses, which averaged 395 mEq (SD, +/- 198) over the first 60 hours of therapy. In the past, injuries of similar severity have been associated with a high incidence of acute renal failure and a high mortality rate, yet none of our patients had azotemia or renal failure. We attribute this success to the unprecedented early institution of appropriate therapy.

Myoglobinuria, 1984

The year is included in the title of this review because the subject is the diversity of conditions that result in myoglobinuria, and new causes keep appearing as conditions in society change or new drugs are introduced. The syndrome is often linked to seamier aspects of society or medicine : war; sadistic drill sergeants; drug abuse; attempted suicide; self-medication or inadequate supervision of drug therapy. On the other hand, study of myoglobinuric syndromes has informed us about new hereditable biochemical causes and we have learned more about the action of viruses on muscle.

Rhabdomyolysis and acute myoglobinuric renal failure associated with methadone intoxication

A case of methadone intoxication is presented. The clinical manifestations were rhabdomyolysis and myoglobinuric acute renal failure. In most cases of drug intoxication, these features occur secondary to previous coma or prolonged immobilization. Since our patient was neither comatose nor immobilized, we suggest that a toxic action of methadone was responsible for rhabdomyolysis.