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Feng D, Fu L, Du X, Yao L. Acute diquat poisoning causes rhabdomyolysis. Am J Med Sci 2022; 364:472-480. [PMID: 35508282 DOI: 10.1016/j.amjms.2022.04.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 01/15/2022] [Accepted: 04/26/2022] [Indexed: 01/25/2023]
Abstract
We studied the case of a 36-year-old female patient who self-administered about 30 ml of diquat solution (200 g/L) during a suicide attempt. She developed nausea, vomiting, dizziness, and weakness in her limbs and was admitted to the emergency department of our hospital 4 h later. The patient developed progressive swelling and pain in both calves 12 h after admission. Based on symptoms, lower limb color Doppler ultrasound, and elevated levels of myoglobin and creatine kinase, the patient was diagnosed with rhabdomyolysis caused by diquat poisoning. The patient recovered and was discharged after treatment with hemoperfusion, continuous venovenous hemodialysis, acid suppression, liver protection, low-dose glucocorticoids, etc. Rhabdomyolysis caused by diquat poisoning has not been previously reported. We attempted to analyze the mechanism of this symptom through a literature review. We recommend the routine monitoring of creatine phosphokinase (CK) and myoglobin (MYO) in patients with diquat poisoning to avoid missed diagnosis. Further, the mechanism of this poisoning symptom was discussed through the literature review.
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Affiliation(s)
- Dongyang Feng
- Department of Emergency Medicine, Fifth Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Linlin Fu
- Department of Emergency Medicine, Fifth Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Xinyu Du
- Department of Emergency Medicine, Fifth Affiliated Hospital of Sun Yat-Sen University, Guangdong, China
| | - Lan Yao
- Department of Emergency Medicine, Fifth Affiliated Hospital of Sun Yat-Sen University, Guangdong, China.
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Abstract
We sought to review the effects of statins on the ryanodine receptor (RyR) and on RyR-associated diseases, with an emphasis on catecholaminergic polymorphic ventricular tachycardia (CPVT). Statins can affect skeletal muscle and produce statin-associated muscle symptoms (SAMS) but have no adverse effects on cardiac muscle. These contrasting effects may be due to differences in how statins affect the skeletal (RyR1) and cardiac (RyR2) RyR. We searched PubMed to identify English language articles reporting the pathophysiology of the RyR, the effect of statins on RyR function, and on RyR-associated genetic diseases. We selected 150 articles for abstract review, 96 of which provided sufficient information to be included and were reviewed in detail. Fifteen articles highlighted the interaction of statins with the RyR. Nine identified the interaction of statins with RyR1, six addressed the interaction of statins with RyR2, 13 suggested that statins reduce ventricular arrhythmias (VA), and seven suggested that statins increase the risk of malignant hyperthermia (MH). In general, statins increase RyR1 and decrease RyR2 activity. We identified no articles examining the effect of statins on CPVT, a condition often caused by defects in RyR2. Statins appear to increase the risk of MH and decrease the risk of ventricular arrhythmia. The effect of statins on CPVT has not been directly examined, but statins' reduction in RyR2 function and their apparent reduction in VA suggest that they may be beneficial in this condition.
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Affiliation(s)
- Mohsin Haseeb
- Division of Cardiology, Loyola University Medical Center, Maywood, Illinois
| | - Paul D Thompson
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
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Morton AB, Norton CE, Jacobsen NL, Fernando CA, Cornelison DDW, Segal SS. Barium chloride injures myofibers through calcium-induced proteolysis with fragmentation of motor nerves and microvessels. Skelet Muscle 2019; 9:27. [PMID: 31694693 PMCID: PMC6833148 DOI: 10.1186/s13395-019-0213-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/30/2019] [Indexed: 12/15/2022] Open
Abstract
Background Local injection of BaCl2 is an established model of acute injury to study the regeneration of skeletal muscle. However, the mechanism by which BaCl2 causes muscle injury is unresolved. Because Ba2+ inhibits K+ channels, we hypothesized that BaCl2 induces myofiber depolarization leading to Ca2+ overload, proteolysis, and membrane disruption. While BaCl2 spares resident satellite cells, its effect on other tissue components integral to contractile function has not been defined. We therefore asked whether motor nerves and microvessels, which control and supply myofibers, are injured by BaCl2 treatment. Methods The intact extensor digitorum longus (EDL) muscle was isolated from male mice (aged 3–4 months) and irrigated with physiological salt solution (PSS) at 37 °C. Myofiber membrane potential (Vm) was recorded using sharp microelectrodes while intracellular calcium concentration ([Ca2+]i) was evaluated with Fura 2 dye. Isometric force production of EDL was measured in situ, proteolytic activity was quantified by calpain degradation of αII-spectrin, and membrane disruption was marked by nuclear staining with propidium iodide (PI). To test for effects on motor nerves and microvessels, tibialis anterior or gluteus maximus muscles were injected with 1.2% BaCl2 (50–75 μL) in vivo followed by immunostaining to evaluate the integrity of respective tissue elements post injury. Data were analyzed using Students t test and analysis of variance with P ≤ 0.05 considered statistically significant. Results Addition of 1.2% BaCl2 to PSS depolarized myofibers from − 79 ± 3 mV to − 17 ± 7 mV with a corresponding rise in [Ca2+]i; isometric force transiently increased from 7.4 ± 0.1 g to 11.1 ± 0.4 g. Following 1 h of BaCl2 exposure, 92 ± 3% of myonuclei stained with PI (vs. 8 ± 3% in controls) with enhanced cleavage of αII-spectrin. Eliminating Ca2+ from PSS prevented the rise in [Ca2+]i and ameliorated myonuclear staining with PI during BaCl2 exposure. Motor axons and capillary networks appeared fragmented within 24 h following injection of 1.2% BaCl2 and morphological integrity deteriorated through 72 h. Conclusions BaCl2 injures myofibers through depolarization of the sarcolemma, causing Ca2+ overload with transient contraction, leading to proteolysis and membrane rupture. Motor innervation and capillarity appear disrupted concomitant with myofiber damage, further compromising muscle integrity.
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Affiliation(s)
- Aaron B Morton
- Department of Medical Pharmacology and Physiology, University of Missouri, MA415 Medical Sciences Building, 1 Hospital Drive, Columbia, MO, 65212, USA
| | - Charles E Norton
- Department of Medical Pharmacology and Physiology, University of Missouri, MA415 Medical Sciences Building, 1 Hospital Drive, Columbia, MO, 65212, USA
| | - Nicole L Jacobsen
- Department of Medical Pharmacology and Physiology, University of Missouri, MA415 Medical Sciences Building, 1 Hospital Drive, Columbia, MO, 65212, USA
| | - Charmain A Fernando
- Department of Medical Pharmacology and Physiology, University of Missouri, MA415 Medical Sciences Building, 1 Hospital Drive, Columbia, MO, 65212, USA
| | - D D W Cornelison
- Division of Biological Sciences and Christopher S. Bond Life Sciences Center, University of Missouri, Columbia, MO, 65201, USA
| | - Steven S Segal
- Department of Medical Pharmacology and Physiology, University of Missouri, MA415 Medical Sciences Building, 1 Hospital Drive, Columbia, MO, 65212, USA. .,Dalton Cardiovascular Research Center, Columbia, MO, 65211, USA.
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A Rare Case of Sunitinib-Induced Rhabdomyolysis in Renal Cell Carcinoma. Case Rep Oncol Med 2018; 2018:3808523. [PMID: 30123592 PMCID: PMC6079559 DOI: 10.1155/2018/3808523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 07/02/2018] [Indexed: 11/17/2022] Open
Abstract
We report a rare case of metastatic renal cell carcinoma (RCC) in a patient who developed rhabdomyolysis while on sunitinib. He was admitted to the hospital due to muscle weakness, fatigue, poor oral intake, and difficulty swallowing in March 2017. He was found to have pancytopenia, liver failure, kidney failure, high uric acid, and increased creatine phosphokinase of more than 5000. He quickly developed lactic acidosis and acute respiratory failure. He was transferred to the ICU, but his condition declined rapidly. He died 3 days later. In this article we discussed about sunitinib-mediated inhibition of adenosine monophosphate kinase (AMPK) as a possible pathophysiology of rhabdomyolysis. Our case is the third sunitinib-induced rhabdomyolysis reported in the literature.
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JSA guideline for the management of malignant hyperthermia crisis 2016. J Anesth 2017; 31:307-317. [DOI: 10.1007/s00540-016-2305-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Indexed: 11/28/2022]
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Jaradat SA, Amayreh W, Al-Qa'qa' K, Krayyem J. Molecular analysis of LPIN1 in Jordanian patients with rhabdomyolysis. Meta Gene 2015; 7:90-4. [PMID: 26909335 PMCID: PMC4733219 DOI: 10.1016/j.mgene.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/15/2015] [Accepted: 12/02/2015] [Indexed: 12/31/2022] Open
Abstract
Recessive mutations in LPIN1, which encodes a phosphatidate phosphatase enzyme, are a frequent cause of severe rhabdomyolysis in childhood. Hence, we sequenced the 19 coding exons of the gene in eight patients with recurrent hereditary myoglobinuria from four unrelated families in Jordan. The long-term goal is to facilitate molecular genetic diagnosis without the need for invasive procedures such as muscle biopsies. Three different mutations were detected, including the novel missense mutation c.2395G>C (Gly799Arg), which was found in two families. The two other mutations, c.2174G>A (Arg725His) and c.1162C>T (Arg388X), have been previously identified, and were found to cosegregate with the disease phenotype in the other two families. Intriguingly, patients homozygous for Arg725His were also homozygous for the c.1828C>T (Pro610Ser) polymorphism, and were exercise-intolerant between myoglobinuria episodes. Notably, patients homozygous for Arg388X were also homozygous for the c.2250G>C silent variant (Gly750Gly). Taken together, the data provide family-based evidence linking hereditary myoglobinuria to pathogenic variations in the C-terminal lipin domain of the enzyme. This finding highlights the functional significance of this domain in the absence of structural information. This is the first analysis of LPIN1 in myoglobinuria patients of Jordanian origin, and the fourth such analysis worldwide. LPIN1 mutations were cataloged in families with hereditary myoglobinuria. A novel missense Gly799Arg mutation was identified. Arg725His, the only other known missense mutation, was confirmed to be pathogenic. Arg388X, a known nonsense mutation, was the most common among Arabic patients. Patients exercise-intolerant between myoglobinuria episodes have a second mutation.
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Affiliation(s)
- Saied A Jaradat
- Princess Haya Biotechnology Center, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Wajdi Amayreh
- Department of Pediatrics, Metabolic Genetics Clinic, Queen Rania Al-Abdullah Children's Hospital, King Hussein Medical Centre, Amman 11855, Jordan
| | - Kefah Al-Qa'qa'
- Department of Pediatrics, Metabolic Genetics Clinic, Queen Rania Al-Abdullah Children's Hospital, King Hussein Medical Centre, Amman 11855, Jordan
| | - Jan Krayyem
- Princess Haya Biotechnology Center, Jordan University of Science and Technology, Irbid 22110, Jordan
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Sousa A, Paiva JA, Fonseca S, Raposo F, Valente L, Vyas D, Ribeiro O, Pinto R. Rhabdomyolysis: risk factors and incidence in polytrauma patients in the absence of major disasters. Eur J Trauma Emerg Surg 2012; 39:131-7. [PMID: 26815069 DOI: 10.1007/s00068-012-0233-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 10/07/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Rhabdomyolysis is a syndrome caused by musculoskeletal tissue damage that leads to the release of large amounts of intracellular elements, which particularly affect renal function. The most common causes are severe trauma, ischemia, surgical procedures, and drug abuse. We aimed to determine the incidence of rhabdomyolysis by measuring muscle injury markers (CK, myoglobin), to identify pre/post-admission as well as iatrogenic risk factors for rhabdomyolysis in severe polytrauma, to clarify the relevance of orthopedic injuries and surgical treatment in the onset/worsening of rhabdomyolysis, and to correlate risk factors with its main complication-acute renal failure (ARF). METHODS Prospective study of severe polytrauma patients (Injury Severity Score (ISS) >15), with CK and myoglobin values measured at admission and after 24, 48, and 72 h. Peak values, variations between admission and peak, and variations between admission and day 3 were all determined. The correlations of those values with the onset of ARF and other negative outcomes were assessed. RESULTS A total of 57 consecutive patients with a median ISS of 29 were included. ARF was present in 20 patients (38 %). CK-0 level was correlated with male gender (p < 0.027) and ISS (0.014); Mb-0 level was correlated with hypovolemic shock (0.003) and skeletal fracture (p < 0.043). CK-max was correlated with surgery (p < 0.038) and surgery duration (p < 0.014); Mb-max was correlated with surgery (p < 0.002) and anesthesia duration (p < 0.005). Δ-CK was correlated with surgery (p < 0.01) and surgery duration (p < 0.017), and Δ0-3-CK was correlated with surgery (p < 0.042). Logistic regression analysis found relationships between Δ0-3-CK and both ICU admission (p < 0.003) and MODS (p < 0.012), and between Mb-max and ARF (p < 0.034). CONCLUSION We found that a large number of factors are implicated in CK and Mb variations. Rhabdomyolysis is a very frequent complication, but increase in CK marker alone does not seem to be correlated with the incidence of ARF. Therefore, Mb level should be considered in this group of patients.
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Affiliation(s)
- A Sousa
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - S Fonseca
- Anesthesiology Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - F Raposo
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - L Valente
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - D Vyas
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA.
| | - O Ribeiro
- Department of Decision and Information Sciences in Health, Faculdade de Medicina da UP, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - R Pinto
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
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Huang LY, Lin CM, Chiou CC, Lin WS, Cheng SM. Rhabdomyolysis as a potential complication of carbamazepine-induced toxic epidermal necrolysis. Clin Biochem 2012; 45:1531-2. [PMID: 22728955 DOI: 10.1016/j.clinbiochem.2012.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 06/05/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
Abstract
Toxic epidermal necrolysis (TEN) is a rare and severe exfoliative skin disorder characterized as widespread epidermis destruction and is usually a drug-induced condition. TEN has a high mortality rate, and multisystemic involvement is very frequent. Gastrointestinal, respiratory, hepatic, pancreatic, ocular, and hematological disturbances are common complications of TEN. Here, we report on a 30-year-old male with TEN who developed concurrent rhabdomyolysis. The exact relationship between TEN and rhabdomyolysis remains unknown. Because of lack of underlying etiology, we hypothesized that rhabdomyolysis is a potential TEN-related complication.
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Affiliation(s)
- Li-Yen Huang
- Department of Critical Care Medicine, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
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9
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Hohenegger M. Drug induced rhabdomyolysis. Curr Opin Pharmacol 2012; 12:335-9. [PMID: 22560920 PMCID: PMC3387368 DOI: 10.1016/j.coph.2012.04.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 04/04/2012] [Accepted: 04/05/2012] [Indexed: 11/05/2022]
Abstract
Rhabdomyolysis is a clinical condition of potential life threatening destruction of skeletal muscle caused by diverse mechanisms including drugs and toxins. Given the fact that structurally not related compounds cause an identical phenotype pinpoints to common targets or pathways, responsible for executing rhabdomyolysis. A drop in myoplasmic ATP paralleled with sustained elevations in cytosolic Ca2+ concentration represents a common signature of rhabdomyolysis. Interestingly, cardiac tissue is hardly affected or only secondary, as a consequence of imbalance in electrolytes or acid–base equilibrium. This dogma is now impaired by compounds, which show up with combined toxicity in heart and skeletal muscle. In this review, cases of rhabdomyolysis with novel recently approved drugs will be explored for new target mechanisms in the light of previously described pathomechanisms.
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Affiliation(s)
- Martin Hohenegger
- Medical University of Vienna, Center for Physiology and Pharmacology, Institute of Pharmacology, Währingerstrasse 13A, A-1090 Vienna, Austria.
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Edwards JGT, Newtont JR, Ramzan PHL, Pilsworth RC, Shepherd MC. The efficacy of dantrolene sodium in controlling exertional rhabdomyolysis in the Thoroughbred racehorse. Equine Vet J 2010; 35:707-11. [PMID: 14649364 DOI: 10.2746/042516403775696221] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY Dantrolene sodium (Dantrium) has been used extensively for the treatment of myopathies in man and anecdotal evidence suggests it is of clinical benefit in the control of exercise-induced rhabdomyolysis (ER) in racehorses, although data to support this are currently lacking. OBJECTIVES To investigate the efficacy of oral dantrolene sodium in controlling ER in a randomised, double-blind, placebo-controlled crossover trial involving 77 Thoroughbred racehorses in Newmarket, UK. METHODS Horses were treated on 2 occasions 1 week apart, with treatment days coinciding with a return to exercise following 2 days box rest on each occasion. For the first treatment, each horse was randomly selected to receive either 800 mg dantrolene sodium or a colour-matched placebo administered orally 1 h before exercise. This was followed by crossover to the other treatment on the second occasion, with each horse thereby acting as its own control. Degree of ER was assessed using rising serum creatine kinase (CK) levels, by subtracting pre-exercise blood CK levels from those measured in 6 h post exercise blood samples. For each horse, the difference in change between pre- and post exercise CK values between placebo and dantrolene treatments was calculated, with positive values indicating a greater rise with placebo than with dantrolene sodium treatment. RESULTS The overall mean difference for all horses was +104.8 iu/l and the null hypothesis, that there was no true difference in non-normally distributed post exercise rises in CK values between placebo and dantrolene treatments, was rejected (P = 0.0013) using the nonparametric Wilcoxon signed rank test. Additionally, no horses given dantrolene sodium showed clinical signs of ER, whereas 3 horses given the placebo developed ER following exercise. The incidence of ER in the study was 4% (3/77). CONCLUSIONS The results confirmed that oral administration of dantrolene sodium, 1 h before exercise, had a statistically significant effect on reducing the difference between pre- and post exercise plasma CK levels compared with a placebo in the same animals, and preventing clinical ER in susceptible individuals. POTENTIAL RELEVANCE This study suggested that dantrolene sodium is of use in controlling ER in the Thoroughbred racehorse. Further investigation into pre- and post exercise myoplasmic calcium levels and the repeat of the study late in the season when horses receive a much higher energy ration and more strenuous exercise would appear to be warranted.
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Affiliation(s)
- J G T Edwards
- Rossdale and Partners, Beaufort Cottage Stables, High Street, Newmarket, Suffolk CB8 8JS, UK
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Chatzizisis YS, Misirli G, Hatzitolios AI, Giannoglou GD. The syndrome of rhabdomyolysis: complications and treatment. Eur J Intern Med 2008; 19:568-74. [PMID: 19046720 DOI: 10.1016/j.ejim.2007.06.037] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 06/21/2007] [Indexed: 12/18/2022]
Abstract
Rhabdomyolysis is a syndrome of skeletal muscle cell damage that leads to the release of toxic intracellular material into the systemic circulation. The pathogenesis of rhabdomyolysis is based on an increase in free ionized calcium in the cytoplasm. Its main complications include (a) acute renal failure, which is triggered by renal vasoconstriction and ischemia, (b) myoglobin cast formation in the distal convoluted tubules, and (c) direct renal toxic effect of myoglobin on the epithelial cells of proximal convoluted tubules. Other major complications include electrolyte disorders, such as hyperkalemia, which may cause cardiac arrhythmias, metabolic acidosis, hyperphosphatemia, early hypocalcemia, and late hypercalcemia. Compartmental syndrome and disseminated intravascular coagulopathy may also emerge. The management of myoglobinuric acute renal failure includes aggressive fluid administration to restore the hypovolemia and urine alkalization. The concomitant electrolyte and metabolic disorders should also be treated appropriately; hemodialysis should be considered when life-threatening hyperkalemia and metabolic acidosis exist. In the case of compartmental syndrome, it is important to monitor the intra-compartmental pressure and to perform fasciotomy, if required. When diagnosed early and if the appropriate treatment is initiated promptly, the complications of rhabdomyolysis are preventable and the syndrome has a good prognosis.
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Affiliation(s)
- Yiannis S Chatzizisis
- AHEPA University Hospital, Aristotle University Medical School, Thessaloniki, Greece
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Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med 2007; 18:90-100. [PMID: 17338959 DOI: 10.1016/j.ejim.2006.09.020] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 09/26/2006] [Indexed: 12/18/2022]
Abstract
Rhabdomyolysis is defined as a pathological condition of skeletal muscle cell damage leading to the release of toxic intracellular material into the blood circulation. Its major causes include trauma, ischemia, drugs, toxins, metabolic disorders, and infections. The pathophysiological hallmark of the syndrome is an increase in intracellular free ionized calcium due to either cellular energy depletion, or direct plasma membrane rupture. The increased intracellular calcium activates several proteases, intensifies skeletal muscle cell contractility, induces mitochondrial dysfunction, and increases the production of reactive oxygen species, ultimately resulting in skeletal muscle cell death. Clinically, the syndrome presents with severe muscular pain, weakness and myoglobinuria. Increased myoglobin and creatine phosphokinase as a consequence of muscular cell death are the major laboratory findings, which, in combination with the clinical presentation, lead the clinician to the final diagnosis of the syndrome.
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Affiliation(s)
- George D Giannoglou
- AHEPA University Hospital, Aristotle University Medical School, 1 St. Kiriakidi Street, 54636, Thessaloniki, Greece
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Lucas da Silva PS, Iglesias SBDO, Waisberg J. Hypokalemic rhabdomyolysis in a child due to amphotericin B therapy. Eur J Pediatr 2007; 166:169-71. [PMID: 16906399 DOI: 10.1007/s00431-006-0208-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2006] [Accepted: 05/30/2006] [Indexed: 10/24/2022]
Abstract
Hypokalemia can result in life-threatening complications if not treated appropriately. Although hypokalemia is a frequent adverse effect of amphotericin B therapy, there are no reports in the pediatric literature on hypokalemia-associated rhabdomyolysis induced by this drug. A ten-year-old boy with a history of one week amphotericin B treatment was admitted with weakness of the lower extremities, inability to walk and calf pain. Laboratory tests showed a serum potassium of 1.7 mEq/L and a serum creatinine phosphokinase of 3937 U/L plus myoglobulinuria. Following fluid expansion and intravenous potassium replacement, the patient progressed to achieve full regression of muscular weakness after one week. This report highlights hypokalemia as a rare cause of rhabdomyolysis. Patients on amphotericin B should be checked for this rare yet potentially life-threatening complication.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal, São Paulo, Brazil.
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Sacher J, Weigl L, Werner M, Szegedi C, Hohenegger M. Delineation of myotoxicity induced by 3-hydroxy-3-methylglutaryl CoA reductase inhibitors in human skeletal muscle cells. J Pharmacol Exp Ther 2005; 314:1032-41. [PMID: 15914674 DOI: 10.1124/jpet.105.086462] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins) are widely used and well tolerated cholesterol-lowering drugs. In rare cases, side effects occur in skeletal muscle, including myositis or even rhabdomyolysis. However, the molecular mechanisms are not well understood that lead to these muscle-specific side effects. Here, we show that statins cause apoptosis in differentiated human skeletal muscle cells. The prototypical representative of statins, simvastatin, triggered sustained intracellular Ca(2+) transients, leading to calpain activation. Intracellular chelation of Ca(2+) completely abrogated cell death. Moreover, ryanodine also completely prevented the simvastatin-induced calpain activation. Nevertheless, an activation of the ryanodine receptor by simvastatin could not be observed. Downstream of the calpain activation simvastatin led to a translocation of Bax to mitochondria in a caspase 8-independent manner. Consecutive activation of caspase 9 and 3 execute apoptotic cell death that was in part reversed by the coadministration of mevalonic acid. Conversely, the simvastatin-induced activation of calpain was not prevented by mevalonic acid. These data delineate the signaling cascade that leads to muscle injury caused by statins. Our observations also have implications for improving the safety of this important medication and explain to some extent why physical exercise aggravates skeletal muscle side effects.
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Affiliation(s)
- Julia Sacher
- Center of Biomolecular Medicine and Pharmacology, Medical University of Vienna, Austria
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López JR, Mijares A, Rojas B, Linares N, Allen PD, Shtifman A. Altered Ca2+ homeostasis in human uremic skeletal muscle: possible involvement of cADPR in elevation of intracellular resting [Ca2+]. Nephron Clin Pract 2005; 100:p51-60. [PMID: 15855809 DOI: 10.1159/000085444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Accepted: 02/15/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic renal failure may develop muscle weakness and fatigability due to disorders of skeletal muscle function, collectively known as the uremic myopathy. Cyclic adenosine diphosphate-ribose (cADPR), an endogenous metabolite of beta-NAD+, activates Ca2+ release from intracellular stores in vertebrate and invertebrate cells. The current study investigated the possible role of cADPR in uremic myopathy. METHODS We have examined the effect of cADPR on myoplasmic resting Ca2+ concentration ([Ca2+]i) in skeletal muscle obtained from control subjects and uremic patients (UP). [Ca2+]i was measured using double-barreled Ca2+-selective microelectrodes in muscle fibers, prior to and after microinjections of cADPR. RESULTS Resting [Ca2+]i was elevated in UP fibers compared with fibers obtained from control subjects. Removal of extracellular Ca2+, or incubation of cells with nifedipine, did not modify [Ca2+]i in UP or control fibers. Microinjection of cADPR produced an elevation of [Ca2+]i in both groups of cells. This elevation was not mediated by Ca2+ influx, or inhibited by heparin or ryanodine. [cADPR]i was determined to be higher in muscle fibers from UP compared to those from the control subjects. Incubation of cells with 8-bromo-cADPR, a cADPR antagonist, partially reduced [Ca2+]i in UP muscle fibers and blocked the cADPR-elicited elevation in [Ca2+]i in both groups of muscle cells. CONCLUSION Skeletal muscles of the UP exhibit chronic elevation of [Ca2+]i that can be partially reduced by application of 8-bromo-cADPR. cADPR was able to mobilize Ca2+ from intracellular stores, by a mechanism that is independent of ryanodine or inositol trisphosphate receptors. It can be postulated that an alteration in the cADPR-signaling pathway may exist in skeletal muscle of the patients suffering from uremic myopathy.
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Affiliation(s)
- José R López
- Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela.
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Hadad E, Cohen-Sivan Y, Heled Y, Epstein Y. Clinical review: Treatment of heat stroke: should dantrolene be considered? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:86-91. [PMID: 15693989 PMCID: PMC1065088 DOI: 10.1186/cc2923] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rapid and efficient cooling is the most important therapeutic objective in patients with heat stroke (HS). This article reviews the mechanism of action and rationale for the use of dantrolene as a potential supportive cooling method in the treatment of HS. Relevant studies were included to support discussion of the role of dantrolene for the treatment of HS. In some studies dantrolene was shown to accelerate cooling rate when administered after the development of exertional HS. Dantrolene was also found to be effective in reducing the extent of HS signs when given as pretreatment in an animal model. Accumulated data do not support the routine use of dantrolene as an adjuvant cooling technique in HS, but administration of this drug in severe cases, or in which no improvement is observed, appears rational. Further trials are needed in order to assess the true effectiveness of dantrolene in HS.
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Affiliation(s)
- Eran Hadad
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Israel
| | - Yoav Cohen-Sivan
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Israel
| | - Yuval Heled
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Israel
| | - Yoram Epstein
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
Exertional rhabdomyolysis is an uncommon diagnosis, but because its complications can be severe, clinicians need a thorough understanding of this syndrome. When skeletal muscle cell membranes are damaged, their intracellular contents enter the bloodstream and can cause potentially serious sequelae, even death. Intense exercise, some viral infections, and certain genetic disorders increase the risk. Serum creatine kinase levels are the diagnostic gold standard. The treatment of rhabdomyolysis consists of early detection, therapy for the underlying cause, measures to prevent renal failure, and correction of metabolic complications.
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Affiliation(s)
- Thomas P Brown
- Training Wing 6, Naval Air Station, Pensacola, FL, 32508-5217, USA. cdr-thomas.p.brown.@cnet.navy.mil
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18
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Abstract
Crush injuries resulting in traumatic rhabdomyolysis are an important cause of acute renal failure. Ischemia reperfusion is the main mechanism of muscle injury. Intravascular volume depletion and renal hypoperfusion, combined with myoglobinuria, result in renal dysfunction. The infusion of intravenous fluids before extrication or soon after injury may lessen the severity of the crush syndrome. Serum CK levels can be used to screen patients with crush injuries to determine injury severity. Once intravascular volume has been stabilized, and the presence of urine flow has been confirmed, a forced mannitol-alkaline diuresis for prophylaxis against hyperkalemia and acute renal failure should be instituted. If an extremity compartment syndrome is suspected, one should have a low threshold for checking the intracompartmental pressures. Further studies are needed to demonstrate if any treatment regimen is truly superior to early, aggressive crystalloid infusion.
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Affiliation(s)
- Darren J Malinoski
- Department of Surgery, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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Affiliation(s)
- Laura M. Criddle
- Laura Criddle is the clinical nurse specialist for the emergency department and the trauma/neuro intensive care unit at Oregon Health & Science University, Portland, Ore
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Abstract
Rhabdomyolysis is the clinical and laboratory syndrome resulting from skeletal muscle injury and release of potentially toxic substances into the circulation. The severity of rhabdomyolysis varies widely from asymptomatic elevation of muscle enzymes to the life-threatening complications of acute renal failure and severe electrolyte abnormalities. The etiology of rhabdomyolysis may be considered under 4 categories: (1) trauma or direct injury, (2) excessive muscle activity, (3) hereditary muscle enzyme defects, and (4) other less obvious medical causes. The latter medical causes may be subdivided into the following: (1) drugs and toxins, (2) muscle hypoxia, (3) metabolic and endocrine disorders, (4) infections, (5) temperature alterations, and (6) miscellaneous causes. The diagnosis of rhabdomyolysis depends on recognizing the symptoms of muscle pain and weakness, detecting the presence of or history of red-to-brown urine (myoglobinuria), and finding short-term elevations of creatine kinase that are not attributable to myocardial infarction or inflammatory myopathies. The major therapeutic goal is to recognize and treat complications as soon as possible, particularly electrolyte abnormalities and acute renal failure. Knowledge of the other medical causes of rhabdomyolysis allows one to identify and treat this potentially serious condition in otherwise occult cases.
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Affiliation(s)
- Ronald C Allison
- Division of Pulmonary andCritical Care Medicine, Department of Internal Medicine, University of South Alabama College of Medicine, Medical Center, 2451 Fillingim Street, Suite 10-G, Mobile, AL 36617, USA.
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Kimura F, Furutama D, Nakajima H, Sugino M. Hypercreatine kinasemia normalized during complete bed-rest in patients with X-linked spinobulbar muscular atrophy. AMYOTROPHIC LATERAL SCLEROSIS AND OTHER MOTOR NEURON DISORDERS : OFFICIAL PUBLICATION OF THE WORLD FEDERATION OF NEUROLOGY, RESEARCH GROUP ON MOTOR NEURON DISEASES 2002; 3:248-9. [PMID: 12710517 DOI: 10.1080/146608202760839013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lentz LR, Valberg SJ, Herold LV, Onan GW, Mickelson JR, Gallant EM. Myoplasmic calcium regulation in myotubes from horses with recurrent exertional rhabdomyolysis. Am J Vet Res 2002; 63:1724-31. [PMID: 12492289 DOI: 10.2460/ajvr.2002.63.1724] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether alterations in myoplasmic calcium regulation can be identified in muscle cell cultures (myotubes) and intact muscle fiber bundles derived from Thoroughbreds affected with recurrent exertional rhabdomyolysis (RER). ANIMALS 6 related Thoroughbreds with RER and 8 clinically normal (control) Thoroughbred or crossbred horses. PROCEDURES Myotube cell cultures were grown from satellite cells obtained from muscle biopsy specimens of RER-affected and control horses. Fura-2 fluorescence was used to measure resting myoplasmic calcium concentration as well as caffeine- and 4-chloro-m-cresol (4-CMC)-induced increases in myoplasmic calcium. In addition, intact intercostal muscle fiber bundles were prepared from both types of horses, and their sensitivities to caffeine- and 4-CMC-induced contractures were determined. RESULTS Myotubes of RER-affected and control horses had identical resting myoplasmic calcium concentrations. Myotubes from RER-affected horses had significantly higher myoplasmic calcium concentrations than myotubes from control horses following the addition of > or = 2mM caffeine; however, there was no difference in their response to 4-CMC (> or = 1 mM). Caffeine contracture thresholds for RER and control intact muscle cell bundles (2 vs 10mM, respectively) were significantly different, but 4-CMC contracture thresholds of muscle bundles from RER-affected and control horses (500 microM) did not differ. CONCLUSIONS AND CLINICAL RELEVANCE An increase in caffeine sensitivity of muscle cells derived from a family of related RER-affected horses was detected in vitro by use of cell culture with calcium imaging and by use of fiber bundle contractility techniques. An alteration in muscle cell calcium regulation is a primary factor in the cause of this heritable myopathy.
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Affiliation(s)
- Linnea R Lentz
- Department of Clinical and Population Sciences, University of Minnesota, St Paul, MN 55108, USA
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Abstract
Rhabdomyolysis, a syndrome of skeletal muscle breakdown with leakage of muscle contents, is frequently accompanied by myoglobinuria, and if sufficiently severe, acute renal failure with potentially life-threatening metabolic derangements may ensue. A diverse spectrum of inherited and acquired disorders affecting muscle membranes, membrane ion channels, and muscle energy supply causes rhabdomyolysis. Common final pathophysiological mechanisms among these causes of rhabdomyolysis include an uncontrolled rise in free intracellular calcium and activation of calcium-dependent proteases, which lead to destruction of myofibrils and lysosomal digestion of muscle fiber contents. Recent advances in molecular genetics and muscle enzyme histochemistry may enable a specific metabolic diagnosis in many patients with idiopathic recurrent rhabdomyolysis.
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Affiliation(s)
- Jason D Warren
- Department of Neurology, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Vanholder R, Sever MS, Erek E, Lameire N. Acute renal failure related to the crush syndrome: towards an era of seismo-nephrology? Nephrol Dial Transplant 2000; 15:1517-21. [PMID: 11007816 DOI: 10.1093/ndt/15.10.1517] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- R Vanholder
- Renal Division, University Hospital, Gent, Renal Disaster Relief Task
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Affiliation(s)
- Raymond Vanholder
- Renal Division, University Hospital, Gent, Belgium (Renal Disaster Relief Task Force of the International Society of Nephrology)
| | - Mehmet Sükrü Sever
- Istanbul Medical Faculty, Çapa Campus, Istanbul, Turkey (local coordinator for the Renal Disaster Relief Task Force)
| | - Ekrem Erek
- Istanbul Medical Faculty, Cerrahpasha Campus, Istanbul, Turkey (President of the Turkish Society of Nephrology)
| | - Norbert Lameire
- Renal Division, University Hospital, Gent, Belgium (coordinator for the European Section of the Renal Disaster Relief Task Force)
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Abstract
Myoglobinuria refers to an abnormal pathologic state in which an excessive amount of myoglobin is found in the urine, imparting a cola-like hue, usually in association with myonecrosis and a clinical picture of weakness, myalgias, and edema. Myoglobinuria is produced by multiple causes: any condition that accelerates the use or interferes with the availability of oxygen or energy substrates to muscle cells can result in myoglobinuria, as can events that produce direct muscle injury, either mechanical or chemical. Acute renal failure is the most serious complication, which can be prevented by prompt, aggressive treatment. In patients surviving acute attacks, recovery of muscle and renal function is usually complete.
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Affiliation(s)
- W S David
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55415, USA.
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Slater MS, Mullins RJ. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review. J Am Coll Surg 1998; 186:693-716. [PMID: 9632160 DOI: 10.1016/s1072-7515(98)00089-1] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M S Slater
- Department of Surgery, Oregon Health Sciences University, Portland 97201, USA
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Lopez JR, Linares N, Brady PA, Terzic A. Cardiac hypertrophy determines digitalis action on intracellular Ca2+ in human myocardium. Eur J Pharmacol 1997; 339:161-4. [PMID: 9473131 DOI: 10.1016/s0014-2999(97)01398-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ventricular hypertrophy alters transporters associated with digitalis action, but the outcome of digitalis treatment on intracellular cations in the hypertrophied human myocardium remains unknown. Using double-barreled Ca2+-selective microelectrodes, we simultaneously measured Ca2+ activity and membrane potential in myocardial samples from patients without and with ventricular hypertrophy, prior to and following exposure to strophanthidin, a prototype digitalis. We found that ventricular hypertrophy is associated with greater strophanthidin-induced increase in diastolic Ca2+ levels compared to that observed in the absence of hypertrophy. Furthermore, in hypertrophied myocardium the magnitude of the increase in Ca2+ induced by strophanthidin was inversely related to increase in myocardial mass. Thus, the extent of ventricular hypertrophy determines digitalis action on intracellular Ca2+ within the human myocardium.
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Affiliation(s)
- J R Lopez
- Centro de Biofisica y Bioquimica, Instituto Venezolano de Investigaciones Cientificas, Caracas, Venezuela
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López JR, Terzic A. Inositol 1,4,5-trisphosphate-induced Ca2+ release is regulated by cytosolic Ca2+ in intact skeletal muscle. Pflugers Arch 1996; 432:782-90. [PMID: 8772127 DOI: 10.1007/s004240050199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Microinjection of inositol 1,4,5-trisphosphate (InsP3) into intact skeletal muscle fibers isolated from frogs (Rana temporaria) increased resting cytosolic Ca2+ concentration ([Ca2+]i) as measured by double-barreled Ca2+-selective microelectrodes. In contrast, microinjection of inositol 1-phosphate, inositol 1,4-biphosphate, and inositol 1,4,5,6-tetrakisphosphate did not induce changes in [Ca2+]i. Incubation in low-Ca2+ solution, or in the presence of L-type Ca2+ channel blockers did not affect InsP3-induced release of cytosolic Ca2+. Neither ruthenium red, a blocker of ryanodine receptor Ca2+-release channels, nor cytosolic Mg2+, a known inhibitor of the Ca2+-induced Ca2+-release process, modified the InsP3-induced release of cytosolic Ca2+. However, heparin, a blocker of InsP3 receptors, inhibited InsP3-induced release of cytosolic Ca2+. Also, pretreatment with dantrolene or azumulene, two inhibitors of cytosolic Ca2+ release, reduced [Ca2+]i, and prevented InsP3 from inducing release of cytosolic Ca2+. Incubation in caffeine or lengthening of the muscle increased [Ca2+]i and enhanced the ability of InsP3 to induce release of cytosolic Ca2+. These results indicate that InsP3, at physiological concentrations, induces Ca2+ release in intact muscle fibers, and suggest that the InsP3-induced Ca2+ release is regulated by [Ca2+]i. A Ca2+-dependent effect of InsP3 on cytosolic Ca2+ release could be of importance under physiological or pathophysiological conditions associated with alterations in cytosolic Ca2+ homeostasis.
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Affiliation(s)
- J R López
- Centro de Biofísica y Bioquímica, Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela
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