Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Failing kidneys: renal replacement therapies in the ICU

Acute kidney injury (AKI) is one of the most common organ dysfunctions impacting ICU (intensive care unit) patients. Early diagnosis using the various classification systems and interventions that can be aided by use of biomarkers are key in improving outcomes. Once the patient meets criteria of AKI, many patient specific factors determine the optimal timing for and mode of renal replacement therapy. There are several special considerations in surgical ICU patients with AKI including management of intracranial hypertension in those with cerebral edema, anticoagulation in high-risk bleeding patients, and use of contrast imaging. This article provides a focused review of the essential aspects of diagnosis and management of AKI in the critically ill or injured surgical patient.

Parental recovered acute kidney injury causes prenatal renal dysfunction and fetal growth restriction with sexually dimorphic implications for adult offspring

Introduction: Acute kidney injury (AKI) is rapidly increasing in global incidence and a healthcare burden. Prior maternal AKI diagnosis correlates with later pregnancy complications. As pregnancy influences developmental programming, we hypothesized that recovered parental AKI results in poor pregnancy outcomes, impaired fetal growth, and adult offspring disease. Methods: Using a well-characterized model of rhabdomyolysis-induced acute kidney injury (RIAKI), a form of AKI commonly observed in young people, we confirmed functional renal recovery by assessing glomerular filtration rate (GFR) 2 weeks following RIAKI. We bred sham and recovered RIAKI sires and dams in timed, matched matings for gestational day (GD) 16.5 and offspring (birth-12 weeks, 6 months) study. Results: Despite a normal GFR pre-pregnancy, recovered RIAKI dams at GD16.5 had impaired renal function, resulting in reduced fetoplacental ratios and offspring survival. Pregnant RIAKI dams also had albuminuria and less renal megalin in the proximal tubule brush border than shams, with renal subcapsular fibrosis and higher diastolic blood pressure. Growth-restricted offspring had a reduced GFR as older adults, with evidence of metabolic inefficiency in male offspring; this correlated with reduced renal AngII levels in female offspring from recovered RIAKI pairings. However, the blood pressures of 6-month-old offspring were unaffected by parental RIAKI. Conclusions: Our mouse model demonstrated a causal relationship among RIAKI, gestational risk, and developmental programming of the adult-onset offspring GFR and metabolic dysregulation despite parental recovery.

Management of kidney injury in critically ill patients with earthquake-induced crush syndrome: A case series of 18 patients

İNTRODUCTION: It was aimed primarily to analyze the development of acute kidney injury (AKI) and treatment management in critically ill patients who developed rhabdomyolysis due to earthquake-related crush syndrome.

METHODS

We evaluated 18 patients with crush syndrome who were admitted to the intensive care unit (ICU) after the great earthquake in February 2023 in Turkey.

RESULTS

AKI occurred in 83% (n:15) of these patients after ICU admission (AKI-1; 16.6% [n:3], AKI-2; 16.6% [n:3], and AKI-3; 50% [n:9]). While the majority of patients who developed crush syndrome were treated with high volume intravenous hydration, only 33% (n:6) of all patients required renal replacement therapy. All patients who developed AKI had complete recovery in renal functions at the end of 2 months.

CONCLUSION

There is no need for routine renal replacement therapy in the treatment of AKI, which is frequently seen in patients with crush syndrome. Most can be treated with high volumes of intravenous fluid.

Unusually high creatine kinase in a case of rhabdomyolysis without acute kidney injury: a case report

Background

While rhabdomyolysis frequently leads to hospital admissions, typically following trauma, recurrent occurrences are relatively rare, accounting for just 10% of cases. For young patients experiencing repetitive episodes without an apparent cause, a comprehensive investigation into the possible etiologies is crucial. Recognizing the atypical nature of recurrent rhabdomyolysis is crucial and a thorough workup encompassing evaluations for potential endocrine, inflammatory, and metabolic etiologies is recommended. Additionally, acute kidney injury is a common complication with severe rhabdomyolysis, hence early recognition and intervention is crucial.

Case Description

Herein we present a case of a 30-year-old young African American male patient with recurrent rhabdomyolysis with the highest ever reported creatine kinase (CK) to our knowledge. A notable aspect of this case is the surprising absence of acute kidney injury, despite the severity of CK elevation. We also delve into the extensive workup done for rhabdomyolysis of unclear etiology.

Conclusions

Our case underscores the importance of looking into non-traumatic factors behind recurrent rhabdomyolysis, especially in young patients. We also stress the significance of early detection and intervention, showcasing the potential to prevent acute kidney injury even in the presence of markedly elevated CK levels. Timely recognition and appropriate management can prove instrumental in mitigating the severity of complications associated with rhabdomyolysis.

Uric acid in predicting the traumatic rhabdomyolysis induced acute kidney injury; a systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis was to assess the value of uric acid in predicting acute kidney injury caused by traumatic rhabdomyolysis.

METHODS

The search was conducted in MEDLINE, Scopus, Embase and Web of Science until November 1, 2023. Based on the inclusion and exclusion criteria, the articles were included by two independent researchers. Data regarding study design, patient characteristics, number of patients with and without AKI, mean and SD of uric acid and prognostic characteristics of uric acid were extracted from relevant studies. STATA version 17.0 was used to compute pooled measures of standardized mean differences, odds ratios, and diagnostic accuracy. I2 and chi-square tests were used to assess heterogeneity between studies.

RESULTS

We found 689 non-redundant studies, 44 of them were potentially relevant. Six articles met the inclusion criteria and were included in the review. The results of the meta-analysis confirmed that there was a significant correlation between serum uric acid levels and the occurrence of AKI (SMD = 1.61, 95% CI = 0.69 to 2.54, I2 = 96.94%; p value = 0.001). There were no significant publication biases.

CONCLUSION

According to this meta-analysis, uric acid levels could be considered as a predictor of acute kidney injury following traumatic rhabdomyolysis.

Rhabdomyolysis as cause, consequence, or mimicker of myocardial infarction: A case report

Key Clinical Message

A timely diagnosis is essential to start appropriate therapy and to reduce risks of life-threatening complications of rhabdomyolysis. Some cases can undergo differential diagnosis with other clinical conditions, e.g., myocardial infarction.

Abstract

We present the case of a 65-years-old male who was admitted to the emergency department with a clinical presentation related to myocardial infarction. The patient underwent coronary angioplasty and was then admitted to ICU due to hemodynamical instability, elevated potassium levels, and anuria. Further investigations revealed rhabdomyolysis. The patient received vasopressors, oxygenation support and renal replacement therapy. Outcomes at ICU discharge were favorable. The temporal association between rhabdomyolysis and myocardial infarction, together with an unclear pathophysiological relationship, made differential diagnosis difficult. We discuss this uncertainty in light of published literature.

Myopathic Carnitine Palmitoyltransferase II (CPT II) Deficiency: A Rare Cause of Acute Kidney Injury and Cardiomyopathy

Carnitine palmitoyltransferase II (CPT II) deficiency is a long-chain fatty acid (LCFA) oxidation disorder. There are three main types classified by symptoms and age of onset: the neonatal form, the infantile hepatocardiomuscular form, and the adult or myopathic form. The first two are early-onset severe disorders presenting with marked hypoketotic hypoglycemia, cardiomyopathy, and liver dysfunction. The latter is characterized by muscle pain and weakness and stiffness, typically triggered by exercise or febrile illnesses and occasionally associated with myoglobinuria. One of the most common complications is acute kidney injury (AKI) following massive rhabdomyolysis, which is managed with aggressive fluid therapy; crystalloid solutions are preferred. We report an otherwise healthy 38-year-old patient who presented with severe myalgia, cramps, fatigue, low-grade fever, and transient myoglobinuria, after intense physical training. Significant recurrent muscle pain was reported. Family history was unremarkable. Imaging studies showed no abnormalities. Echocardiogram showed a left ventricle ejection fraction (LVEF) of 40%. Acetylcarnitine analysis with tandem mass spectrometry and molecular tests confirmed the diagnosis. Fluid resuscitation was started. Acute kidney injury was diagnosed and managed with plasmapheresis and five sessions of hemodialysis. The patient was discharged upon the improvement of renal function with lifestyle modification recommendations. In otherwise healthy young adults presenting with myalgia and rhabdomyolysis triggered by physical activity or infection, CPT II deficiency should be considered, and genetic testing should be initiated to provide an opportunity for patients to modify their daily lifestyle, preventing future attacks and the development of complications.

Progress in the Diagnostic and Predictive Evaluation of Crush Syndrome

Crush syndrome (CS), also known as traumatic rhabdomyolysis, is a syndrome with a wide clinical spectrum; it is caused by external compression, which often occurs in earthquakes, wars, and traffic accidents, especially in large-scale disasters. Crush syndrome is the second leading cause of death after direct trauma in earthquakes. A series of clinical complications caused by crush syndrome, including hyperkalemia, myoglobinuria, and, in particular, acute kidney injury (AKI), is the main cause of death in crush syndrome. The early diagnosis of crush syndrome, the correct evaluation of its severity, and accurate predictions of a poor prognosis can provide personalized suggestions for rescuers to carry out early treatments and reduce mortality. This review summarizes various methods for the diagnostic and predictive evaluation of crush syndrome, including urine dipstick tests for a large number of victims, traditional and emerging biomarkers, imaging-assisted diagnostic methods, and developed evaluation models, with the aim of providing materials for scholars in this research field.

Mini Review of Biochemical Basis, Diagnosis and Management of Crush Syndrome

Crush syndrome (CS) is a metabolic disorder whose victims are individuals suffered from natural disasters such as earthquake or man-made conflicts. CS complications include acute kidney injury and cardiac arrhythmia that collectively end with death if untreated immediately. These complications are accounted for the liberation of damaged muscle tissues contents, primarily myoglobin and potassium. The present mini review discusses the biochemical basis of the development of CS. In addition, diagnosis and management and the application of novel experimental therapeutics of CS are also highlighted.

Exploring the association between selective serotonin reuptake inhibitors and rhabdomyolysis risk based on the FDA pharmacovigilance database

Rhabdomyolysis is a syndrome potentially fatal and has been associated with selective serotonin reuptake inhibitors (SSRIs) treatment in a few case reports. Herein, we purpose to establish the correlation between SSRIs use and rhabdomyolysis using the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. We conducted an analysis on reports that were submitted to the FAERS database during the period between January 1, 2004, and December 31, 2022. Four algorithms, including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and empirical Bayes geometric mean (EBGM), were employed to quantify the signals of rhabdomyolysis associated with SSRIs. In total, 16,011,277 non-duplicated reports were obtained and analyzed. Among 33,574 reports related to rhabdomyolysis, SSRIs were classified as primary suspected drug in 889 cases. Disproportionality analysis identified a positive signal between rhabdomyolysis and SSRIs (ROR: 2.86, 95% CI 2.67-3.05; PRR: 2.84, χ²: 1037.16; IC_0.25 = 1.39; EBGM_0.5 = 2.64). Among six SSRIs, fluvoxamine had the strongest signal (ROR: 11.64, 95% CI 8.00-16.93; PRR: 11.38, χ²: 265.51; IC_0.25 = 2.41; EBGM_0.5 = 8.31), whereas no significant signal of rhabdomyolysis was detected for paroxetine (ROR: 1.83, 95% CI 1.55-2.15; PRR: 1.82, χ²: 53.82; IC_0.25 = 0.73; EBGM_0.5 = 1.59). After excluding cases co-administered with statins, the signal of rhabdomyolysis associated with SSRIs remains significant. Our analysis reveals that there are differences in safety signals among six SSRIs in respect to the risk of rhabdomyolysis, with fluvoxamine displaying the highest risk signal, while paroxetine did not show a significant signal. Given the potentially lethal nature of rhabdomyolysis, healthcare professionals should inform patients of the potential risk of rhabdomyolysis associated with SSRIs prior to initiating treatment.

Study of the Relationship Between Liver Function Markers and Traumatic Rhabdomyolysis: A Retrospective Study of Hemorrhagic Patients Admitted to Intensive Care Unit in a Level I Trauma Center

BACKGROUND

Traumatic rhabdomyolysis (RM) is common and contributes to the development of medical complications, of which acute renal failure is the best described. Some authors have described an association between elevated aminotransferases and RM, suggesting the possibility of associated liver damage. Our study aims to evaluate the relationship between liver function and RM in hemorrhagic trauma patients.

METHODS

This is a retrospective observational study conducted in a level 1 trauma center analyzing 272 severely injured patients transfused within 24 hours and admitted to intensive care unit (ICU) from January 2015 to June 2021. Patients with significant direct liver injury (abdominal Abbreviated Injury Score [AIS] >3) were excluded. Clinical and laboratory data were reviewed, and groups were stratified according to the presence of intense RM (creatine kinase [CK] >5000 U/L). Liver failure was defined by a prothrombin time (PT)-ratio <50% and an alanine transferase (ALT) >500 U/L simultaneously. Correlation analysis was performed using Pearson's or Spearman's coefficient depending on the distribution after log transformation to evaluate the association between serum CK and biological markers of hepatic function. Risk factors for the development of liver failure were defined with a stepwise logistic regression analysis of all relevant explanatory factors significantly associated with the bivariate analysis.

RESULTS

RM (CK >1000 U/L) was highly prevalent in the global cohort (58.1%), and 55 (23.2%) patients presented with intense RM. We found a significant positive correlation between RM biomarkers (CK and myoglobin) and liver biomarkers (aspartate transferase [AST], ALT, and bilirubin). Log-CK was positively correlated with log-AST (r = 0.625, P < .001) and log-ALT (r = 0.507, P < .001) and minimally with log-bilirubin (r = 0.262, P < .001). Intensive care unit stays were longer for intense RM patients (7 [4-18] days vs 4 [2-11] days, P < .001). These patients required increased renal replacement therapy use (4.1% vs 20.0%, P < .001) and transfusion requirements. Liver failure was more common (4.6% vs 18.2%, P < .001) for intense RM patients. It was associated with bivariate and multivariable analysis with intense RM (odds ratio [OR], 4.51 [1.11-19.2]; P = .034), need for renal replacement therapy, and Sepsis-Related Organ Failure Assessment Score (SOFA) score on day 1.

CONCLUSIONS

Our study established the presence of an association between trauma-related RM and classical hepatic biomarkers. Liver failure was associated with the presence of intense RM in bivariate and multivariable analysis. Traumatic RM could have a role in the development of other system failures, specifically at the hepatic level, in addition to the already known and well-described renal failure.

Association between preoperative serum myoglobin and acute kidney injury after Stanford Type A aortic dissection surgery

BACKGROUND

Acute kidney injury (AKI) is a common complication after Type A aortic dissection (TAAD) surgery, and it is associated with poor outcomes. The nephrotoxic effect of myoglobin was established, but its correlation with AKI following TAAD repair still lacks sufficient evidence. We clarified the correlation between preoperative serum myoglobin (pre-sMyo) concentrations and AKI after TAAD surgery.

METHOD

A retrospective analysis was performed on the perioperative data of 382 patients treated with TAAD surgery at Beijing Anzhen Hospital. AKI was defined and classified according to the criteria established by the Kidney Disease: Improving Global Outcomes Acute Kidney Injury Work Group. We attempted to determine the correlation between pre-sMyo concentrations and postoperative AKI.

RESULTS

The incidences of Stage 1, 2, and 3 AKI were 37.3 % (57/153), 23.5 % (36/153), and 39.2 % (60/153), respectively. The pre-sMyo concentrations of the AKI group were significantly increased than the non-AKI group [43.1 (21.4, 107.5) vs 26.4 (18.0, 37.2), P < 0.001]. Pre-sMyo concentrations have a linear correlation with preoperative renal function-related indicators. The multivariable logistic regression analysis showed that Ln (pre-sMyo) was an independent risk factor for AKI. When the pre-sMyo concentration was at the fourth quartile [109.3 (64.8, 213.4) ng/ml], the risk of developing any-stage and severe AKI was significantly increased (OR = 4.333, 95 % CI: 2.364-7.943, P < 0.001; OR = 3.862, 95 %, CI: 2.011-7.419, P < 0.001). This difference persisted after adjustment (OR = 3.830, 95 % CI: 1.848-7.936, P < 0.001; OR = 2.330, 95 % CI: 1.045-5.199, P = 0.039). Furthermore, pre-sMyo concentrations were not affected by lower limb malperfusion, myocardial malperfusion, and cardiac tamponade.

CONCLUSIONS

Increased pre-sMyo concentrations correlated with postoperative AKI in TAAD, which may increase the risk of developing any-stage AKI and severe AKI after TAAD surgery.

Earlier continuous renal replacement therapy is associated with reduced mortality in rhabdomyolysis patients

Background

Continuous renal replacement therapy (CRRT) is commonly employed for rhabdomyolysis (RM) patients. However, the optimal initiation timing of CRRT and prognostic factors were not well evaluated for patients with RM. We aimed to investigate the efficacy of CRRT timing on mortality and the risk factors for death in RM patients who received CRRT.

Methods

RM patients who received CRRT between 1 May 2010 and 31 May 2021 in our center were retrospectively included. Univariate and multivariate logistic analyses were performed to identify the risk factors for primary outcome (90-day mortality).

Results

A total of 134 patients were included in our study. The 90-day mortality rate was 38.06%. The median time from CRRT initiation to peak CK occurrence was 4.8 h (IQR −16, 14), 67 patients received CRRT before 4.8 h after peak CK occurrence (early CRRT), and 67 patients received CRRT beyond 4.8 h after peak CK occurrence (late CRRT). Multivariate logistic regression analysis showed that the time from CRRT initiation to the peak CK (per 1 h, OR 1.026, 95% CI 1.004–1.049, p = 0.023), late CRRT (OR 3.082, 95% CI 1.072–8.859, p = 0.037), elevated serum cardiac troponin I (cTnI) (per 1 ng/mL, OR 1.218, 95% CI 1.011–1.468, p = 0.038), older age (per 1 year, OR 1.042, 95% CI 1.003–1.081, p = 0.032), and need of mechanical ventilation support (OR 4.632, 95% CI 1.292–16.61, p = 0.019) were independent risk factors for 90-day mortality.

Conclusions

Earlier CRRT initiation before 4.8 h after peak CK occurrence was associated with lower 90-day patient mortality.

Rhabdomyolysis Caused by Hypothyroidism: Research Progress

Rhabdomyolysis (RM) refers to the clinical syndrome caused by the release of intracellular substances into the extracellular fluid and blood circulation after rhabdomyocyte destruction due to various etiologies. In severe cases, RM can lead to life-threatening conditions such as acute kidney injury. Hypothyroidism is a rare cause of RM that can lead to missed diagnosis or misdiagnosis, and the condition worsens in the absence of timely and effective treatment. Herein, reported cases of RM caused by hypothyroidism are summarized, and clinical diagnosis and treatment recommendations are proposed to facilitate early identification and treatment of the disease.

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.