Clinical factors in predicting acute renal failure caused by rhabdomyolysis in the ED

Purpose

This study aimed to determine the clinical factors in predicting acute renal failure (ARF) in rhabdomyolysis and investigate the potential risk of renal replacement therapy (RRT).

Basic Procedures

From 2006 to 2011, we retrospectively analyzed 202 patients 65 years or younger with a definite diagnosis of rhabdomyolysis and serum creatinine phosphokinase levels greater than 1000 IU/L. The related clinical factors were analyzed in the patients with ARF caused by rhabdomyolysis. In addition, receiver operating characteristic curves were used to establish the appropriate cutoff values of serum biomarkers in predicting ARF.

Main Findings

The most common causes of rhabdomyolysis were trauma (n = 54; 26.7%) and infections (n = 37; 18.3%). Of the 202 patients, 29 (14.4%) developed ARF, and RRT was indicated for 5 of these 29 patients. Predictive factors for ARF were dark urine, initial and peak serum myoglobin level, rhabdomyolysis caused by body temperature change, and an elevated serum potassium level. Receiver operating characteristic analysis showed that the best cutoff value of initial serum myoglobin level for predicting ARF was 597.5 ng/mL. Risk factors for RRT in patients with ARF were etiologies of rhabdomyolysis, peak blood urea nitrogen and creatinine levels, and the creatinine phosphokinase level on the third day as rhabdomyolysis developed.

Principal Conclusions

Age, dark urine, etiologies, serum levels of blood urea nitrogen, creatinine and potassium, and initial and peak serum myoglobin levels may serve as important factors in predicting ARF in patients with rhabdomyolysis. We suggest that the appropriate cutoff value of initial serum myoglobin for predicting ARF is 600 ng/mL.     

Investigating the role of endogenous opioids and KATP channels in glycerol-induced acute renal failure

The present study was designed to investigate the possible role of endogenous opioids and K(ATP) channels in glycerol-induced acute renal failure (ARF) in rats. The rats were subjected to rhabdomyolytic ARF by single intramuscular injection of hypertonic glycerol (50% v/v; 8 mL/kg), and the animals were sacrificed after 24 h of glycerol injection. The plasma creatinine, blood urea nitrogen, creatinine clearance, and histopathological studies were performed to assess the degree of renal injury. Naltrexone (2.5, 5.0 and 10.0 mg/kg s.c.), glibenclamide (5.0 and 10.0 mg/kg i.p.), and minoxidil (25 and 50 mg/kg) were employed to explore the role of endogenous opioids and K(ATP) channels in rhabdomyolysis-induced ARF. Pretreatment with naltrexone and glibenclamide attenuated hypertonic glycerol-induced renal dysfunction in a dose-dependent manner, suggesting the role of endogenous opioids and K(ATP) channels in the pathogenesis of myoglobuniric renal failure. However, the simultaneous pretreatment with naltrexone (10 mg/kg s.c.) and glibenclamide (10 mg/kg i.p.) did not enhance the reno-protective effects of individual drugs, suggesting that release of endogenous opioids and opening of K(ATP) channels constitute a single pathway in acute renal injury triggered by hypertonic glycerol-induced rhabdomyolysis. Furthermore, administration of minoxidil abolished the attenuating effects of naltrexone in glycerol-induced renal failure, suggesting that opening of K(ATP) channels is downstream to opioid receptor activation. It is concluded that hypertonic glycerol-induced rhabdomyolysis may involve release of endogenous opioids that in turn modulate K(ATP) channels to contribute in the pathogenesis of ARF.     

Rapid fall in blood myoglobin in massive rhabdomyolysis and acute renal failure

Objective Myoglobin kinetics of removal from the circulation were studied in patients following massive rhabdomyolysis, to see if myoglobin remains for long in the circulation in the anuric state and if myoglobin elimination was affected by therapeutic manipulation such as haemofiltration or haemodialysis.Design Randomised and controlled study.Setting Intensive care unit of a tertiary care teaching hospital.Patients 26 patients of rhabdomyolysis whose serum myoglobin exceeded more than 500 nmol/l. Thirteen patients developed acute renal failure and underwent treatment with blood purification (Group HD). The remaining 13 patients did not require treatment with blood purification (control subjects, Group non-HD).Interventions In patients of group HD, twelve were treated with haemofiltration and/or haemodialysis. One was treated with peritoneal dialysis. The patient of group non-HD were treated with fluid infusion alone.Measurements and results The serum concentrations of myoglobin were serially determined. The highest levels of myoglobin was 1641±484 nmol/l (mean±SEM) in the group non-HD and were 8957±2300 in the group HD. In the group non-HD, the blood myoglobin fell exponentially once myoglobin release into the circulation ceased. This was also noted in the group HD. The exponential decrease was observed even on the days when the patient passed little urine or treatment with blood purification was not performed.Conclusion In patients with massive myoglobinaemia, the blood myoglobin rapidly fell independent of renal function or any therapeutic manipulation. The results indicate that extrarenal factors played a major role in disposing circulating myoglobin in such patients.     

Myoglobinopathy as a cause of acute interstitial nephritis

The course of the acute renal failure (ARF) was studied in 3 patients with rhabdomyolysis (1 with the position compression syndrome, 1 with march myoglobinuria, and 1 with chronic recurrent rhabdomyolysis). The ARF syndromes were revealed in 2 patients 5-7 days after onset of the disease; in 1 patient (chronic recurrent rhabdomyolysis), ARF recurred. This suggests that the patients developed acute interstitial nephritis (AIN) Prolonged myolytic conditions due to ill-timed initiation of treatment led to the fact that AIN was complicated by ARF in 2 patients, and 1 patient with chronic myopathy had an "immune readiness" for myoglobin to affect the kidneys, which also resulted in ARF. It was stressed that the methods of extracorporeal detoxification (hemodialysis, hemosorption) were highly effective in treating AIN and ARF.     

Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis

OBJECTIVE: We assessed the primary causes of rhabdomyolysis, the factors associated with the development of acute renal failure (ARF), and the need for hemodialysis (HD) among a series of patients presenting to an urban emergency department with rhabdomyolysis. METHODS: A chart review between January 1992 and December 1995 was conducted of patients aged 18 years or older with a diagnosis of rhabdomyolysis and an initial serum creatine phosphokinase greater than 1000 U/L. Patients were excluded if they had evidence of myocardial ischemia, cerebrovascular insufficiency, or the development of rhabdomyolysis after hospitalization. Demographic information, presumed causative factors, past medical history, medication usage, and laboratory data were collected. RESULTS: Ninety-seven patients (93 men, 4 women) were enrolled, with a mean age of 35.7 years. The most common causes of rhabdomyolysis were cocaine (30), exercise (29), and immobilization (18). Seventeen of 97 (17.5%) patients developed ARF; 8 patients (8.25%) needed HD. Several clinical and laboratory factors were statistically associated with development of ARF and need for HD. The only variable that was predictive of both ARF and need for HD in separate multivariate regression models was the initial creatinine (Cr). Initial blood urea nitrogen also was predictive of the need for HD. No patient developed ARF with an initial Cr less than 1.7 mg/dL. CONCLUSION: Acute renal failure and need for HD are common complications of rhabdomyolysis. Except for initial serum Cr and blood urea nitrogen, clinical and laboratory factors were not reliable predictors for the development of ARF or need for HD.     

Elimination kinetics of myoglobin and creatine kinase in rhabdomyolysis: implications for follow-up

OBJECTIVE: Creatine kinase and myoglobin are markers of muscular damage in rhabdomyolysis. Whereas myoglobin is considered to be the principal compound causing tubular damage, serum creatine kinase level is presently guiding therapeutic interventions in clinical practice to prevent acute renal failure. Because differences in elimination kinetics of these two compounds may influence therapeutic decisions, we studied elimination kinetics of myoglobin and creatine kinase in patients with rhabdomyolysis. DESIGN: Open, noncomparative study. SETTING: Intensive and intermediary care units in a university hospital. PATIENTS: A total of 13 consecutive patients with rhabdomyolysis whose baseline serum creatine kinase exceeded 5000 IU/L. Ten of 13 patients were treated with forced alkaline diuresis, and none were dialyzed. RESULTS: Myoglobin had faster elimination kinetics than creatine kinase (p <.01), and the average times to reach the 50% level of initial values were 12 hrs for myoglobin and 42 hrs for creatine kinase. Elimination of myoglobin was not affected by glomerular filtration rate. Compared with creatinine clearance (mean, 102 mL/min), myoglobin clearance was low (mean, 3 mL/min), both in patients with preserved renal function (n = 11) and in those with acute renal failure (n = 2). CONCLUSION: Serum myoglobin has faster elimination kinetics than creatine kinase in patients treated with forced alkaline diuresis for rhabdomyolysis. Considering the etiologic role of myoglobin, our data suggest that serum myoglobin level, rather than that of creatine kinase, should be used to guide therapy in patients with rhabdomyolysis.     

Mécanismes et prise en charge de la tubulopathie liée à la rhabdomyolyse

Severe damage of skeletal muscle, referred to as rhabdomyolysis, is the cause of 10% of acute kidney injury (AKI) cases and AKI complicates 13–50% of traumatic or nontraumatic rhabdomyolysis. Hypovolemia and the direct nephrotoxic effect of myoglobin are thought to be the main factors involved in rhabdomyolysis-induced AKI. Myoglobin promotes kidney injuries through vasoconstrictive properties, proximal tubular injuries, and distal obstruction. Recently, we demonstrated that macrophages influence the long-term prognosis of this disease by exerting proinflammatory as well as profibrotic properties. Clinical management relies on early diagnosis (creatine kinase > 5,000 UI/l) and fluid resuscitation using isotonic sodium chloride. Despite optimal rehydration, patients can develop AKI and require renal replacement therapy (RRT). Severe hyperkalemia or metabolic acidosis is the main cause of RRT. Thus, intermittent hemodialysis rather than continuous RRT should be used as frontline RRT, if available. To date, alkalinization, as well as prophylactic intermittent hemodialysis with high cut-off membrane, did not demonstrate superiority on long-term renal function compared to conventional approach. While global prognosis is depending upon the cause of rhabdomyolysis, mortality increases from 22% to 59% as soon as patients develop AKI. Long-term prognosis is unknown. Animal models demonstrated that rhabdomyolysis can lead to renal fibrosis after several months of followup. This suggests that patients with rhabdomyolysis should be considered as at high risk to develop chronic kidney disease and therefore referred to nephrologists to minimize long-term consequences of chronic kidney disease.     

声学造影定量评价急性肾功能衰竭 肾皮质血流灌注的实验研究

目的　探讨应用自制白蛋白氟碳声学造影剂和声学密度定量技术定量评价急性肾功能衰竭 (ARF)肾皮质血流灌注的可行性。方法　兔后腿肌注 5 0 %甘油 (12～ 15ml/kg) ,建立ARF动物模型。分别于注射甘油前和注射甘油后第三天应用声学造影剂和声学密度定量 (AD)技术检查肾脏 ,观察造影增强效果 ,测定肾皮质造影前后峰值密度 (PI)、曲线下面积 (AUC)和平均通过时间 (MTT)。结果　正常肾脏造影增强效果明显好于ARF肾 ,二者视觉判断差异显著 ;正常肾和ARF肾造影后肾皮质PI、AUC均比造影前明显增加 ,但ARF肾皮质造影后PI、AUC却低于正常肾皮质造影后PI、AUC(P<0 .0 1) ,MTT则变化不大。结论　急性肾小管坏死性肾衰竭时 ,由于肾皮质血流灌注减少 ,引起造影后PI、AUC等有关反映血流灌注的参数也随之下降 ,与正常肾脏差异显著。因此 ,采用经静脉声学造影和声学密度定量技术 ,能够对ARF时肾皮质血流灌注作出定量评价。     

Acute kidney injury induced by thrombotic microangiopathy in two cases of Bothrops envenomation

Context: Bothrops snakes are the most frequent agents of snakebites in South and Central America. Acute kidney injury (AKI) is one of its complications and has multifactorial origin. Thrombotic microangiopathy (TMA)-induced AKI in snakebites is uncommon and is not described in Bothrops envenomation.

Case details: We report two cases of patients bitten by young Bothrops jararaca who developed AKI induced by TMA. Both patients evolved with mild envenomation and received the specific antivenom within 4?h after the snakebite. None of them had hypotension or shock, bleeding or secondary infection. Patient 1 (P1) was diabetic and using oral hypoglycemic drugs, and patient 2 (P2) was hypertensive without regular use of medication. On admission, both patients had levels of fibrinogen lower than 35?mg/dL, D-dimer higher than 10,000?ng/mL. They evolved with AKI, thrombocytopenia, normal coagulation assays, anemia, lactate dehydrogenase (LDH) elevation, low haptoglobin levels, negative direct antiglobulin test, and presence of schizocytes in peripheral blood. Only P1 required renal replacement therapy, and plasmapheresis was not required. Both patients were discharged and did not require outpatient dialysis, and subsequently had normal creatinine levels.

Discussion: TMA may occur in Bothrops jararaca envenomation, even in mild cases that received early specific antivenom.     

Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey

OBJECTIVE: To evaluate the risk factors for the development of acute renal failure (ARF) in severe rhabdomyolysis. DESIGN: Observational historical cohort study. SETTING: General intensive care unit of a university hospital. PATIENTS: Twenty-six patients with severe rhabdomyolysis, who were admitted between July 1996 and July 2001. MEASUREMENTS AND RESULTS: Clinical and laboratory data were reviewed and groups were stratified according to presence or absence of acute renal failure. The underlying cause of rhabdomyolysis was ischemia by vascular obstruction (50%), crush injury by trauma (23%), sepsis (11.5%), heatstroke/hyperthermia (11.5%) and hyponatremia in a single patient. Mean creatine kinase (CK) level was 38,351+/-35,354 U/l on admission and rose further in all patients (mean: 59,747+/-67,514 U/l). Renal failure developed in 17 patients (65%). Serum CK levels correlated with onset of ARF, as these patients had significantly higher admission and peak serum CK concentrations. Patients with ARF had a higher mortality (59% vs 22%). CONCLUSION: In our cohort of patients with severe rhabdomyolysis the level of serum CK predicted the development of ARF. Although our results suggest that series of CK determination might be beneficial for the evaluation of the effect of therapy, the value of CK determination as a prognostic tool is limited, given the wide range of CK levels.     

CRRT联合HP治疗横纹肌溶解综合征伴急性肾损伤的效果及护理

目的探讨连续性肾脏替代治疗（CRRT）联合血液灌流（HP）治疗横纹肌溶解综合征（RM）伴急性肾损伤的临床疗效及护理方法。方法应用CRRT联合HP治疗RM伴急性肾损伤病人12例,给予恰当的护理,观察治疗前、治疗12、24h后病人血肌红蛋白（Mb）、肌酸激酶（CK）、肌酐（Cr）水平变化。结果与治疗前比较,治疗12、24h后病人血Mb、CK、Cr显著下降,差异有显著性（F=4.75~9.68,P〈0.05）。结论应用CRRT联合HP治疗RM伴急性肾损伤,可明显改善肾功能。     

创伤性挤压综合征急性肾功能衰竭的超声评价

目的 探讨超声评价创伤性挤压综合征并发急性肾衰竭(ARF)及监测临床治疗效果的价值.方法 回顾性分析10例地震伤挤压综合征急性肾功能衰竭患者的超声检查与临床资料,并与同期单纯四肢骨折伤患者资料进行对照.结果 10例并ARF患者中,肌酐(Scr)水平及尿素氮(BUN)水平均显著升高(P<0.01),双肾体积增大、动脉阻力指数增高(P<0.01),其中7例患者入院时人血白蛋白水平明显降低(P<0.01),经治疗后均恢复正常.结论 超声对挤压综合征患者肾功能评价及监测临床治疗效果具有较大的价值.     

Fenofibrate-induced rhabdomyolysis in a patient with chronic renal failure due to nephrotic syndrome: a rare case report

ObjectivesFenofibrate is a fibric acid derivative that is used alone or combination with statins in the treatment of hyperlipidemia. These drugs have potential risks, including rhabdomyolysis and acute renal failure. Despite reports of rhabdomyolysis with the use of fenofibrate alone or with statin-fibrate combinations, there have been no cases of rhabdomyolysis described when fenofibrate was used alone to treat patients with chronic renal failure owing to nephrotic syndrome.Design and methodsWe report on a 26-year-old male who presented with fenofibrate-induced rhabdomyolysis with chronic renal failure due to nephrotic syndrome.ResultsAfter the discontinuation of fenofibrate, the patient was treated with intravenous fluid replacement and urine alkalization. Subsequently, his clinical and biochemical findings improved.ConclusionsBefore starting fenofibrate therapy, the causes of secondary hyperlipidemia, especially nephrotic syndrome, should be investigated. In the presence of chronic renal failure and hypoalbuminemia, the fenofibrate dose should be adjusted. Physicians should be aware of the potential toxicities of fenofibrate, and patients should be informed about its potential side effects.     

Bacterial sepsis-induced rhabdomyolysis

Objective: To describe the syndrome of rhabdomyolysis during bacterial sepsis with regard to incidence, blood bacteriology and complications and to examine the association between hyperosmolal state and rhabdomyolysis, evaluating the relationship between plasma osmolality (Posm) and serum creatine phosphokinase (CPK) levels. Design: Prospective study including all patients admitted to the intensive care unit (ICU) for sepsis with positive blood culture and rhabdomyolysis over a 3-year period. Setting: Seven-bed medical/surgical ICU of a teaching hospital. Patients: 35 patients (group 1) with bacterial sepsis-induced rhabdomyolysis (15 males, 20 females; mean age 71 ± 13 years) and 122 (group 2) bacteraemic septic patients without rhabdomyolysis (49 males, 73 females; mean age 68 ± 15) were studied. Patients with rhabdomyolysis were divided into gram( + ) and gram(–) subgroups according to the blood culture growth. Results: From 491 patients recorded, 35 fulfilled the inclusion criteria for bacterial sepsis-induced rhabdomyolysis (7.1 %). Gram-positive bacteria predominated in group 1 (69 %), while gram-negative predominated (60 %) in group 2. There was a correlation between CPK and Posm levels in the rhabdomyolysis Group (r = 0.52, R ² = 0.27, p = 0.003). There was a stronger correlation between these two variables (r = 0.67, R ² = 0.45, p = 0.001) in the gram( + ) subgroup. Acute renal failure (68.5 %) and electrolyte disorders such as hyperkalaemia (34 %) and hypocalcaemia (48.5 %) were the major complications in the rhabdomyolysis group. Sixteen (45.7 %) patients in group 1 and 49 (40 %) in group 2 died during their stay in the ICU from sepsis and multiple organ failure. Rhabdomyolysis was not considered a contributing factor to their death, as none of our patients died during or immediately after the syndrome. Conclusion: Bacterial sepsis-induced rhabdomyolysis results from certain types of microorganisms, mainly gram-positive and to a lesser extent gram-negative. Hyperosmolality is a predisposing mechanism for rhabdomyolysis during bacteraemic sepsis from any type of bacterial microorganism. Received: 5 January 1998 Final revision received: 12 November 1998 Accepted: 18 January 1999     

可溶性生长刺激表达基因2蛋白对免疫检查点抑制剂相关心肌炎预后的预测价值

目的:探讨可溶性生长刺激表达基因2蛋白(soluble growth stimulation expressed gene 2 protein, sST2)对免疫检查点抑制剂相关心肌炎(immune checkpoint inhibitor-associated myocarditis, ICIAM)患者预后的预测价值。方法:选择2019年1月1日至2020年12月31日复旦大学附属中山医院肿瘤心脏病学多学科联合门诊随访的ICIAM患者19例,收集患者一般资料、随访期间心肌损伤标志物水平、sST2水平、影像检查结果及预后情况。根据预后情况分为生存组(n=15)和死亡组(n=4),采用ROC曲线分析sST2水平对预后的预测价值。结果:死亡组治疗期间sST2峰值浓度高于生存组,差异有统计学意义[156.50(91.60, 410.60) ng/mL vs 54.65(18.20, 97.40) ng/mL,P=0.014],两组其余指标差异均无统计学意义。sST2峰值浓度与患者生存负相关(r=-0.683,P=0.010)。ROC分析显示,sST2为87.5 ng/mL时,AUC为0.967,敏感度为90.0%,特异度为100.0%。结论:sST2可较好地预测ICIAM患者预后,为患者治疗计划的制定和更新提供依据。     

Risk factors for acute renal failure in trauma patients

Abstract Objective: To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma. Design: Prospective observational study. Setting: A general intensive care unit (ICU) of a university hospital. Patients: A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months. Results: Forty-eight (31 %) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p < 0.001), higher mortality (p < 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS > 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) > 10 000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score < 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure > 6 cm H₂O, rhabdomyolysis with CPK > 10 000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF. Conclusions: The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies. Received: 22 September 1997 Accepted: 14 May 1998     

Relationship between blood toxin level and clinical features in patients with grayanotoxin poisoning – six clinical cases

Background: The purpose of this study was to investigate grayanotoxin (GTX) levels in the blood of patients with GTX intoxication and in the consumed Rhododendron liqueur, and to determine whether there was an association between blood GTX level and the patient’s clinical status.

Methods: In September 2015, six patients were concurrently presented to the emergency department with various toxicity symptoms, which occurred after the consumption of Rhododendron liqueur at the same toxin concentration. Liquid chromatography–tandem mass spectrometry analysis was conducted on blood samples obtained from six cases of GTX intoxication treated in our emergency department.

Results: At the initial evaluation in the emergency department, the mean arterial pressure of the patients ranged from 36.7 to 76.7?mm?Hg. The concentrations of GTX-I and GTX-III in Rhododendron liqueur were 1.436 and 16.907?ng/mL, respectively. The initial blood GTX-III and GTX-I levels ranged from 2.9 to 58.0?ng/mL and the lower limit of quantification (LLOQ) to 8.33?ng/mL, respectively. After 20?h, the mean arterial pressure ranged from 76.7 to 93.3?mm?Hg, while the blood GTX-III and GTX-I levels ranged from the LLOQ to 17.8 and 2.52?ng/mL, respectively.

Discussion: We estimated that the minimum blood GTX-III and GTX-I levels that caused hypotension were between 17.83 and 27.3?ng/mL, and 2.52 and 4.55?ng/mL, respectively.     

Intramuscular hematoma in rhabdomyolysis patients treated with low-molecular-weight heparin: Report of two cases

BACKGROUNDRhabdomyolysis is a serious complication of heat stroke. Unlike that in acute kidney injury, the risk of muscle bleeding in rhabdomyolysis is often ignored and can substantially increase via the widespread use of anticoagulants, leading to the formation of intramuscular hematoma.CASE SUMMARYDuring the summer, a middle-aged man and an elderly man were diagnosed with heat stroke, rhabdomyolysis, and acute renal impairment. Low-dose enoxaparin sodium was initiated for prophylaxis of deep vein thrombosis after the disease was stabilized with continuous renal replacement therapy. After that, the patients'' hemoglobin decreased progressively, and no obvious intracranial, thoracic, digestive, or skin bleeding tendency was found. However, one of the patients had hip muscle pain, and computed tomography and color ultrasound confirmed that the patients separately had lumbar back and hip intermuscular hematoma. After discontinuation of anticoagulant drugs and monitoring of the steady increase in hemoglobin, the intermuscular hematomas were gradually absorbed. Following the use of prophylactic anticoagulation therapy, the patients'' hemoglobin showed a progressive downward trend. Hematoma formation in the lumbosacral and buttock muscles was confirmed after excluding bleeding in typical regions (such as the digestive tract, thoracic cavity, and abdominal cavity). Anticoagulant drugs were discontinued immediately, and nutritional support was increased. Subsequently, the hemoglobin levels gradually increased, and the hematoma volumes gradually decreased.CONCLUSIONPatients with rhabdomyolysis have a risk of muscle bleeding, and inappropriate use of anticoagulants may lead to an increased risk or even to the formation of an intermuscular hematoma. When continuous blood loss is found in the body, the possibility of bleeding in the muscles and more typical sites should be considered.     

Plasma neutrophil gelatinase-associated lipocalin as a predictive biomarker for the detection of acute kidney injury in adult poisoning

Context: Acute kidney injury (AKI) is a serious complication in intoxicated patients. Recently, a new biomarker - neutrophil gelatinase-associated lipocalin (NGAL) - was used to predict AKI in patients who were critically ill or had sepsis. Objective: To evaluate the utility of plasma NGAL as an early predictor of AKI in adults with acute poisoning. Materials and methods: This retrospective, observational, cohort study was conducted between December 2013 and November 2014. A total of 157 consecutive adult patients who presented to the emergency department (Level 1 regional center) of Kyungpook National University Hospital, a tertiary teaching hospital in Daegu, Korea, within 24 h of poisoning were included. Initial plasma NGAL levels and laboratory parameters were concurrently measured upon hospital arrival. AKI was defined according to Acute Kidney Injury Network criteria. Development of AKI was predicted using plasma NGAL levels and by analyzing the area under the receiver operating characteristic curve (AUC). Results: The overall rate of AKI was 14.6% (n?=?23). Plasma NGAL levels in the AKI group were higher than those in the non-AKI group (median, 310 vs. 86 ng/mL; p?<0.001). Additionally, baseline NGAL levels allowed for better prediction of AKI than initial creatinine levels. The AUC of plasma NGAL was 0.895 (95% confidence interval [CI]: 0.832–0.941), with a cut-off value of 227 ng/mL (sensitivity, 76.2%; specificity, 95.8%). Plasma NGAL had a higher predictive capacity for AKI than serum creatinine (AUC 0.741, 95% CI: 0.662–0.810), base deficit (AUC 0.795, 95% CI: 0.701–0.870), lactate (AUC 0.781, 95% CI: 0.690–0.856), and anion gap (AUC 0.636, 95% CI: 0.535–0.730). Conclusion: Plasma NGAL may serve as a good predictor of AKI in cases of adult poisoning.     

Acute renal failure in intensive care burn patients (ARF in burn patients).

The purpose of this study was to establish the incidence and mortality of burn patients with acute renal failure (ARF) at the Helsinki Burn Centre and to analyze the associated factors. The files of 238 intensive care (ICU) patients of a total of 1380 burn patients admitted to our institution between November 1988 and December 2001 were studied retrospectively. Of all admitted burn patients, 17.2% needed ICU. According to our criteria (S-Cr >120 micromol/l = 1.4 mg/dl), 39.1% of the ICU patients suffered from ARF and one in three of these required renal replacement therapy. The proportion of all admitted burn patients requiring renal replacement therapy was 2.3%. The mortality of ICU patients with ARF was 44.1% whereas that of patients without ARF was only 6.9%. Renal function recovered in all survivors. The nonsurvivors had a larger burned total body surface area, were older, and had more inhalation injuries and a higher abbreviated burn severity index score. The prognosis for patients with early ARF was worse than that for patients with late ARF. Rhabdomyolysis caused by flame injury was associated with high mortality. In this study we observed that ARF is associated with higher mortality even in minor burns when compared with patients without ARF. Flame burn with rhabdomyolysis and subsequent ARF predicts very poor survival. If a patient with severe ARF survives, the renal failure recovers over time.