Massive Rhabdomyolysis; A Rare Cause of Hepatocellular Dysfunction

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.

Acute Budd Chiari syndrome in an ECMO patient

INTRODUCTION

Point-of-care ultrasound (POCUS) is widely utilized to make timely decisions regarding patient care. This approach allowed us to diagnose the cause of acutely rising transaminases in a patient in severe ARDS secondary to influenza pneumonia requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO).

CASE REPORT

A 36-year-old female presented with acute hypoxemic respiratory failure secondary to influenza A infection. Within 24 hours, she required intubation and met severe ARDS criteria with a PaO₂/FiO₂ ratio of 62. She was managed with high PEEP and low tidal volume ventilation strategy, however her clinical status continued to deteriorate and the decision was made to pursue VV-ECMO. Within hours of cannulation her aspartate aminotransferase (AST) dramatically increased from 736 to 4512 µ/L, with concurrent mild increases in alanine aminotransferase (ALT) and creatine phosphokinase (CPK). Point-of-care ultrasound was performed which revealed a complete absence of flow in the hepatic vein, secondary to acute obstruction by an 25-French drainage catheter for the ECMO circuit. The catheter was exchanged with a smaller French catheter and the patient's transaminases and CPK levels quickly decreased and returned to normal within several days.

DISCUSSION

Budd-Chiari syndrome (BCS) is a rare but potentially life-threatening condition caused by acute obstruction of hepatic vein blood flow that can lead to fulminant liver failure if left untreated. BCS is usually caused by a hepatic vein thrombus, however any mechanical obstruction can lead to the same pathology. Point-of-care ultrasound lead to a prompt diagnosis and allowed for quick action to correct the obstruction. Although BCS is not a common problem with VV-ECMO, the syndrome should always be on the differential of any patient on VV-ECMO with acutely rising transaminases.

CONCLUSION

Ultrasound played an integral role in providing a crucial diagnosis of BCS secondary to obstruction by an ECMO drainage catheter.