Acute renal failure due to rhabdomyolysis following a seizure

Electronic phenotyping of health outcomes of interest using a linked claims-electronic health record database: Findings from a machine learning pilot project

OBJECTIVE

Claims-based algorithms are used in the Food and Drug Administration Sentinel Active Risk Identification and Analysis System to identify occurrences of health outcomes of interest (HOIs) for medical product safety assessment. This project aimed to apply machine learning classification techniques to demonstrate the feasibility of developing a claims-based algorithm to predict an HOI in structured electronic health record (EHR) data.

MATERIALS AND METHODS

We used the 2015-2019 IBM MarketScan Explorys Claims-EMR Data Set, linking administrative claims and EHR data at the patient level. We focused on a single HOI, rhabdomyolysis, defined by EHR laboratory test results. Using claims-based predictors, we applied machine learning techniques to predict the HOI: logistic regression, LASSO (least absolute shrinkage and selection operator), random forests, support vector machines, artificial neural nets, and an ensemble method (Super Learner).

RESULTS

The study cohort included 32 956 patients and 39 499 encounters. Model performance (positive predictive value [PPV], sensitivity, specificity, area under the receiver-operating characteristic curve) varied considerably across techniques. The area under the receiver-operating characteristic curve exceeded 0.80 in most model variations.

DISCUSSION

For the main Food and Drug Administration use case of assessing risk of rhabdomyolysis after drug use, a model with a high PPV is typically preferred. The Super Learner ensemble model without adjustment for class imbalance achieved a PPV of 75.6%, substantially better than a previously used human expert-developed model (PPV = 44.0%).

CONCLUSIONS

It is feasible to use machine learning methods to predict an EHR-derived HOI with claims-based predictors. Modeling strategies can be adapted for intended uses, including surveillance, identification of cases for chart review, and outcomes research.

Prolonged Seizure Activity Followed by Severe Hyperphosphatemia and Hypocalcemia in a Pediatric Patient

Seizures secondary to hypocalcemia have been well documented and studied. There are various causes of hypocalcemia described in the literature, but a prolonged seizure episode leading to cell lysis, severe hyperphosphatemia, and hypocalcemia is rarely reported. We present the case of a 3-year-old male with severe hyperphosphatemia and hypocalcemia secondary to the likely presence of cell lysis from prolonged seizure activity. Our case illustrates the importance of a thorough evaluation of the possible differentials of hypocalcemia and hyperphosphatemia in a challenging presentation.

Heat stroke with bimodal rhabdomyolysis: a case report and review of the literature

BACKGROUND

Severe heat stroke tends to be complicated with rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis usually occurs in the acute phase of heat stroke. We herein report a case of heat stroke in a patient who experienced bimodal rhabdomyolysis in the acute and recovery phases.

CASE PRESENTATION

A 34-year-old male patient was found lying unconscious on the road after participating in a half marathon in the spring. It was a sunny day with a maximum temperature of 24.2 °C. His medical and family history was unremarkable. Upon arrival, his Glasgow Coma Scale score was 10. However, the patient's marked restlessness and confusion returned. A sedative was administered and tracheal intubation was performed. On the second day of hospitalization, a blood analysis was compatible with a diagnosis of acute hepatic failure; thus, he received fresh frozen plasma and a platelet transfusion was performed, following plasma exchange and continuous hemodiafiltration. The patient's creatinine phosphokinesis (CPK) level increased to 8832 IU/L on the fifth day of hospitalization and then showed a tendency to transiently decrease. The patient was extubated on the eighth day of hospitalization after the improvement of his laboratory data. From the ninth day of hospitalization, gradual rehabilitation was initiated. However, he felt pain in both legs and his CPK level increased again. Despite the cessation of all drugs and rehabilitation, his CPK level increased to 105,945 IU/L on the 15th day of hospitalization. Fortunately, his CPK level decreased with a fluid infusion. The patient's rehabilitation was restarted after his CPK level fell to <10,000 IU/L. On the 31st day of hospitalization, his CK level decreased to 623 IU/L and he was discharged on foot. Later, a genetic analysis revealed that he had a thermolabile genetic phenotype of carnitine palmitoyltransferase II (CPT II).

CONCLUSIONS

Physicians should pay special attention to the stress of rehabilitation exercises, which may cause collapsed muscles that are injured by severe heat stroke to repeatedly flare up.

Creatinine as predictor value of mortality and acute kidney injury in rhabdomyolysis

BACKGROUND

Rhabdomyolysis (RB) is a syndrome characterised by decomposition of skeletal muscle that could be life threatening, so the identification of biomarkers of its severity could help us in its treatment. Creatine kinase (CK) is usually taken as a reference in patients with RB in order to stratify prognosis, however that is not probably the most effective parameter.

AIMS

The present study was designed to analyse the specific features and mortality of patients with RB and the relation between creatinine, CK and mortality.

METHODS

Retrospective cohort analysis among patients admitted to San Pedro Hospital in Logroño (Spain) with RB (CK levels higher than 2000 U/L) diagnosed since 1 January 2009 until 31 December 2; 013 522 patients with RB patients diagnosed of RB were collected. The aetiology and the analytical feature (creatinine, CK, calcium, phosphorus, pH and bicarbonate), as well as 30-year mortality, were investigated.

RESULTS

Among the 522 patients, there were 138 deaths. Four patients required renal replacement therapy. The most common cause of RB was trauma (29%). Infectious aetiology had the highest mortality (41.2%). The median CK was 3451 u/L (interquartile range 3348), and the mean creatinine at admission was 132.6 umol/L (±110.5). Initial CK levels do not have predictive ability on mortality or renal dysfunction in contrast to initial creatinine values. Each state of acute kidney injury (AKI) increased mortality compared with those who have not presented this renal dysfunction (P < 0.0001). Age, calcium, phosphorus, bicarbonate and pH are associated with AKI.

CONCLUSION

Despite being a diagnostic marker for RB, initial CK levels do not predict mortality. However, creatinine initial levels are related to progression to acute renal injury and mortality at 30 days.

Refractory status epilepticus, serious rhabdomyolysis, acute liver injury, and pancytopenia after a massive intake of ethyl methanesulfonate: a case report

Ethyl methanesulfonate is a mutagenic, alkylating agent and considered harmful to humans at levels greater than a certain threshold; however, the toxicity at high doses remains unclear. We report a case of a Japanese man who presented with status epilepticus, rhabdomyolysis, pancytopenia, and hair loss after accidental ingestion of a massive amount of ethyl methanesulfonate. The patient completely recovered with critical care, including multiple antiepileptic drugs, renal replacement therapy, blood transfusion, granulocyte colony-stimulating factor therapy, and antibacterial/fungal prophylaxis. The case indicates that ethyl methanesulfonate causes neurotoxicity, hepatotoxicity, hematotoxicity, and renal toxicity, which can be successfully treated with appropriate palliative therapies.

[Severe rhabdomyolysis secondary to severe hypernatraemic dehydration]

INTRODUCTION

Rhabdomyolysis is a rare paediatric condition. The case is presented of a patient in whom this developed secondary to severe hypernatraemic dehydration following acute diarrhoea.

CASE REPORT

Infant 11 months of age who presented with vomiting, fever, diarrhoea and anuria for 15 hours. Parents reported adequate preparation of artificial formula and oral rehydration solution. He was admitted with malaise, severe dehydration signs and symptoms, cyanosis, and low reactivity. The laboratory tests highlighted severe metabolic acidosis, hypernatraemia and pre-renal kidney failure (Sodium [Na] plasma 181 mEq/L, urine density> 1030). He was managed in Intensive Care Unit with gradual clinical and renal function improvement. On the third day, slight axial hypotonia and elevated cell lysis enzymes (creatine phosphokinase 75,076 IU/L) were observed, interpreted as rhabdomyolysis. He was treated with intravenous rehydration up to 1.5 times the basal requirements, and he showed a good clinical and biochemical response, being discharged 12 days after admission without motor sequelae.

CONCLUSIONS

Severe hypernatraemia is described as a rare cause of rhabdomyolysis and renal failure. In critically ill patients, it is important to have a high index of suspicion for rhabdomyolysis and performing serial determinations of creatine phosphokinase for early detection and treatment.