Acute renal failure and rhabdomyolysis

Rhabdomyolysis: a review of the literature

Rhabdomyolysis (lysis of skeletal muscle cells) is a potentially lethal syndrome with a broad spectrum of clinical and biochemical findings. Myalgia, pigmenturia and elevated activity of serum creatine kinase are the common features. Fulminant rhabdomyolysis may be associated with severe metabolic disturbances and involvement of other organ systems. Cardiac arrest, compartment syndrome and acute renal failure are the major complications. The extent of the life-threatening complications of rhabdomyolysis strongly depends on early diagnosis and adequate therapy. As the repair mechanism of striated muscle functions very well, the prognosis of adequately treated rhabdomyolysis is excellent. This article reviews the present state of knowledge of clinical and biochemical diagnosis of rhabdomyolysis, the pathophysiologic background, the classification and the etiological provocative factors.

Potassium and anaesthesia

Potassium is the principle intracellular ion, and its concentration and gradients greatly influence the electrical activity of excitable membranes. Because anaesthesia is so intimately involved with electrically active cells, potassium concentrations in surgical patients have received considerable attention in diagnostic and therapeutic applications. With the ongoing evolution in the indications for potassium, it is important to review the role of potassium in cellular activity, in storage and regulation, in diseases that alter potassium homeostasis, and in the therapeutic implications of perioperative alterations of potassium concentration. A rational approach to abnormal potassium values and the use of potassium in the operating room is sought, based on a physiological understanding of risks and benefits.

Crush injury and crush syndrome

Crush injury is caused by continuous prolonged pressure on the limbs. It is found in patients extricated after being trapped for at least 4 hours. The main injury is to the muscles of the limbs. Treatment should be conservative and fasciotomy should be avoided. If fasciotomy is performed, it should be followed by radical debridement of the injured muscle in an attempt to avoid infection of the injured limb. Infection endangers the patient's life and is the main cause of morbidity and mortality today. The outcome of conservative local treatment of crush injury is much superior to that of operative treatment. The pathophysiology of crush injury is not fully understood and no good animal model is known. Crush syndrome, which is the general manifestation of crush injury, is better understood. If not prevented, it will lead to acute renal failure. A method for preventing acute renal failure is discussed and a protocol is described. There is no doubt that prevention of acute renal failure is the goal in the treatment of crush syndrome and can be achieved.

Evidence against oxidant injury and endotoxin underlying glycerol-induced fatal rhabdomyolysis in rats

Rhabdomyolysis in experimental animals and in man may be fatal. The mechanism of action causing death in man and in the experimental model of laboratory animals injected with glycerol in a dose causing fatal rhabdomyolysis is unknown. The aim of this study was to examine two possible causes of death following glycerol injection (0.5-2 ml/100 g) to the leg muscle of rats following a period of water deprivation (24-72 h). The first factor examined was free radical formation, via the administration of various antioxidants such as natural antioxidant (NAO - 5 mg/100 g), vitamin E (0.2 mg/100 g each day for 7 days), dimethylthiourea (DMTU - 50 mg/100 g) and superoxide dismutase (SOD - 0.8 mg/100 g). The second factor was a high blood endotoxin level due to the glycerol injection. This possibility was examined by glycerol injection to rats that had developed endotoxin tolerance. The low survival rate (0-30%) of rats receiving a glycerol injection following preventive treatment with antioxidants as well as rats which had developed endotoxin tolerance (0-40%), excludes the possibility that the cause of death in the glycerol model resulting in fatal rhabdomyolysis is due to free radical formation or to a high and unneutralized blood level of endotoxin.

Effects of changes in plasma volume on fatal rhabdomyolysis in the rat induced by glycerol injections

Rhabdomyolysis can be fatal in both experimental animals and man, but very little is known of the factors causing increased mortality in rhabdomyolysis. The aims of this study were to create an animal model of fatal rhabdomyolysis in rats by a glycerol injection into the leg muscle, and to elucidate some of the factors affecting mortality as a result of rhabdomyolysis formation. In this study, two factors which can result in increased mortality in rats as a result of glycerol injection, were examined. These factors include varying doses of 50% glycerol (0.5-2 ml/100 g) and various stages of dehydration prior to glycerol injection. Dehydration was induced by 1: chronic dehydration, in which the rats underwent water deprivation for a period of 24 to 72 hours prior to injection of glycerol; 2: acute dehydration, by the induction of either diuresis, by injecting sucrose (200-600 mg/100 g) to the femoral vein, or hemorrhage (0.7-2.1 ml/100 g). The results demonstrate that the mortality rate in rats increased in all three models of dehydration as the dose of glycerol injected to the rats increased (above a dose of 0.75 ml/100 g) and as the extent of dehydration increased. Use of a blood substitute before or after glycerol injection in order to compensate for the loss of body fluids did not increase the survival rate of the glycerol-injected rats. In contradistinction, rats treated with non-lethal doses of glycerol exhibited substantial resistance to a second lethal dose of glycerol, injected two weeks following the first injection.

Rhabdomyolysis and myoglobinuria associated with violent exercise and alcohol abuse: report of two cases

Two cases of acute rhabdomyolysis with myoglobinuria and high levels of serum enzyme are presented. The first patient developed acute renal insufficiency in the context of a binge and heavy alcohol drinking lasting several days. He was treated with haemodialysis for three weeks, and survived. The second patient developed rhabdomyolysis and heavy myoglobinuria after playing squash vigorously. Forced mannitol-alkaline diuresis therapy for prophylaxis against hyperkalaemia and metabolic acidosis was performed. He did not develop renal failure. The clinical features, pathology and treatment of rhabdomyolysis and myoglobinuria are summarized.

The role of reperfusion-induced injury in the pathogenesis of the crush syndrome

The crush syndrome consists of the general manifestations that follow prolonged continuous pressure on the limbs. These manifestations are caused by the disintegration of muscle tissue and leakage of the contents of myocytes into the plasma. The morbidity and mortality associated with this syndrome are high. The pathophysiologic process of the derangements associated with the crush syndrome is not fully understood, but the injury induced by reperfusion is likely to be important in its development. The injury due to reperfusion involves many factors, but it is currently ascribed largely to the release of oxygen free radicals, massive accumulation of calcium in ischemic muscles, and the infiltration of neutrophils into reperfused vessels. Since ischemic muscles cannot survive without reperfusion, a strategy to salvage as much of the muscle and kidney tissue as possible in the crush syndrome must include ways of decreasing injury during ischemia and reperfusion. Various pharmacologic agents may attenuate or prevent reperfusion-induced injury to ischemic skeletal muscles and consequently to other organs, particularly the kidneys.

Rhabdomyolysis and operating position

Rhabdomyolysis during routine surgery was studied in three groups of patients who had surgery, with limited trauma to muscle, in the lateral and supine positions, and prone on the spinal frame. A range of blood tests was performed (before surgery, and on the first, third and seventh day after operation). These showed that a creatine kinase increase in the 24 hours and the early appearance of myoglobin in the serum were the best indicators. Rhabdomyolysis was associated with the lateral position and long lasting surgery. No blood test before surgery was of any predictive value.

Benefit of vascular decongestion in glycerol-induced acute renal failure

The post insult administration of vascular decongestants has resulted in attenuation of experimental acute renal failure (ARF) following the introduction of various nephrotoxins including drugs, heavy metals, and endotoxin. In the present study, the dose-dependent effects of a novel methylxanthine, HWA-138, were studied in the glycerol-induced murine model of ARF. Renal function, assessed by serial inulin clearances at 24 and 48 h after glycerol injection, urinary electrolyte excretion rates, and renal morphology, was compared between controls and those given glycerol and single i.v. doses of 0.1, 0.5, 1.0, 5.0, and 10.0 mg/kg of HWA-138, or physiologic saline. Whereas significant renal dysfunction was found in all animal groups given glycerol, the mean inulin clearance values of animals given HWA-138 1 mg/kg closely approximated values found in control rats. There were no changes in renal electrolyte excretion rates in animals given HWA-138 compared with relative natriuresis found in untreated glycerol ARF rat. Although a modest decrease in medullary congestion was associated with rats given 1 mg/kg of HWA-138, there was no obvious structural improvement found with HWA-138. The present data provide further evidence of the potential of methylxanthines in the glycerol-ARF murine model.

Rhabdomyolysis induced by a caffeine overdose

We present the case of a patient who ingested approximately 3.57 g of caffeine in a suicide attempt and developed rhabdomyolysis and acute renal failure. After a delay in diagnosis, the patient was hospitalized and rapidly improved with peritoneal dialysis and volume expansion, but was left with residual impairment of renal function on discharge. This case represents a rarely reported complication of caffeine intoxication, rhabdomyolysis, which occurred in the absence of other toxins or conditions that predispose to muscle necrosis.

A study of the mechanisms of proteinuria in nephritis and chronic renal failure

This study was carried out on 50 patients suffering from renal disorders; 30 nephritis patients and 20 chronic renal failure patients. Twenty-four healthy persons were used as a control group. In order to cast some light on the degree of the impaired glomerular permeability with respect to the blood proteins, selectivity of proteinuria was assessed by means of the clearance of albumin, ceruloplasmin, transferrin, and haptoglobin. Disturbances in the metabolism of these proteins were observed and discussed in light of the proteinuria selectivity index. The demonstration of the selective proteinuria in the presence of haptoglobin was concluded to be indicative of the degree of impaired glomerular permeability in nephritis and chronic renal failure.

Acute renal failure in sickle-cell disease

Two patients with reversible acute oligoanuric renal failure in the setting of sickle-cell crisis are presented. The renal failure could not be attributed to volume depletion, urinary tract obstruction, or exogenous nephrotoxins. There were several features in each case that suggested the presence of nontraumatic rhabdomyolysis. The possible role of pigmenturia in the pathogenesis of the reversible renal failure in sickle-cell crisis is discussed.

Acute worsening of renal function during episodes of macroscopic hematuria in IgA nephropathy

The appearance of renal failure during episodes of macroscopic hematuria (EMH) in IgA nephropathy (IgAN) has been described as very unusual. The results of a prospective investigation on the effect of EMH on renal function in IgAN are presented. During a 3-year period, 29 episodes of EMH occurring in 21 patients with IgAN have been studied. A derangement of renal function (increase of serum creatinine by more than 0.5 mg/dl) was observed in 11 episodes (37.9%) with peak creatinine values ranging from 1.2 to 6.7 mg/dl. The worsening of renal function was accompanied by a longer duration of EMH (4.8 +/- 1.3 vs. 3.5 +/- 1.5 days; P less than 0.05) but not by arterial hypertension or edema. A complete recovery of renal function was observed in every patient 1 to 2 months after the start of EMH. The histological survey disclosed that the decrease of renal function correlated closely with the presence of red blood cell casts in as much as 50% of the tubular lumen and with findings of tubular necrosis. We conclude that a worsening of renal function can be observed frequently during the EMH. Tubular damage and obstruction by red blood cell casts may play a significant role in the pathogenesis of this complication.

Fatal overdose from a sustained-release theophylline preparation

A 26-year-old woman ingested approximately 9 g of theophylline (Theodur). She exhibited agitation, generalized seizures, hyperglycemia, hypokalemia, hypomagnesemia, hypophosphatemia, and diuresis. Later in her hospital course rhabdomyolysis, myoglobinuria, and acute renal failure occurred. Hemodialysis was performed to correct electrolyte imbalance. She subsequently died of intractable shock and hyperkalemia. This case illustrates the metabolic abnormalities which may occur with severe theophylline intoxication.