Rhabdomyolysis and acute renal failure in intensive care unit

Rhabdomyolysis is common clinical and laboratory syndrome resulting from skeletal muscle injury and acute renal failure is the most important complication. Acute renal failure is common in critically ill medical patients. The aim of our study was to determine the prevalence of rhabdomyolysis induced acute renal failure in these patients and to established the prognosis of critically ill patients with acute renal failure and rhabdomyolysis. In the study were included 1557 patients treated in our medical intensive care unit. Seventy-three patients had criteria for acute renal failure. Twelve of them (16.4%) had rhabdomyolysis, eight were women and four were men (average age was 71 years). Sixty-one patients (83.6%) had acute renal failure without rhabdomyolysis, 33 were women and 28 were men (average age was 69 years). We found no difference in age and sex between patients with acute renal failure with or without rhabdomyolysis. Ten patients (83.3%) with rhabdomyolysis and 39 patients (63.9%) without rhabdomyolysis had multiorgan failure syndrome. In patients with rhabdomyolysis, the number of failing organs were statistically significantly higher (p < 0.027). Nine patients (75%) with rhabdomyolysis and 27 patients (44.3%) without rhabdomyolysis died. Mortality was statistically significantly higher (p < 0.05) in patients with rhabdomyolysis. Rhabdomyolysis with acute renal failure was frequently observed in patients treated in our medical intensive care unit. Multiorgan failure syndrome was common in these patients and mortality was higher compared to patients without rhabdomyolysis.     

Pheochromocytoma presenting with rhabdomyolysis and acute renal failure: a case report

Rhabdomyolysis ranges from an asymptomatic illness with elevated creatine kinase levels to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure, and disseminated intravascular coagulation. The most common causes are crush injury, overexertion, alcohol abuse, certain medicines, and toxic substances. A number of electrolyte abnormalities and endocrinopathies, including hypothyroidism, thyrotoxicosis, diabetic ketoacidosis, nonketotic hyperosmolar state, and hyperaldosteronism, cause rhabdomyolysis. Rhabdomyolysis and acute renal failure are unusual manifestations of pheochromocytoma. There are a few case reports with pheochromocytoma presenting rhabdomyolysis and acute renal failure. Herein, we report a case with pheochromocytoma crisis presenting with rhabdomyolysis and acute renal failure.     

Acute forearm compressive myopathy syndrome secondary to upper limb entrapment: an unusual cause of renal failure

Compressive myopathy syndrome (SCM) is a syndrome characterized by the lesion of skeletal muscle resulting in subsequent release of intracellular contents (myoglobin, creatine phosphokinase, potassium, etc.) into the circulatory system, which can cause potentially lethal complications. There are numerous causes that can lead to SCM resulting to acute rhabdomyolysis, and many patients present with multiple causes. The most common potentially lethal complication is acute renal failure. The occurrence of acute rhabdomyolysis should be considered as a possibility in any patient who can remain stationary for long periods, or is in a coma, or is intoxicated in any form. We report the rare case of a 26-year-old patient who developed SCM caused by ischemia reperfusion, with subsequent acute rhabdomyolysis and acute renal failure after prolonged compression of the right upper extremity.     

Acute renal failure in McArdle's disease

This is a report of a case of acute renal failure associated with McArdle's disease. A 45-year-old man had acute renal failure that required dialysis. His case was subsequently diagnosed as rhabdomyolysis secondary to McArdle's disease, a primary myopathy due to myophosphorylase deficiency. History-taking revealed nothing suspected to be responsible for precipitating the renal failure.     

Snakebite nephropathy

There is a broad clinical spectrum of renal involvement in snakebite. Besides the local and systemic symptoms, clinical renal manifestations vary from mild proteinuria, haematuria, pigmenturia to acute renal failure. Bites by haemotoxic snakes and myotoxic snakes are the common causes of renal involvement especially acute renal failure. Therefore, renal failure is often associated with haemorrhagic diathesis, intravascular haemolysis and rhabdomyolysis. Renal pathological changes include mesangiolysis, glomerulonephritis, vasculitis, tubular necrosis, interstitial nephritis and cortical necrosis. Tubular necrosis is an important pathological counterpart of acute renal failure. Haemodynamic alterations induced by cytokines and vasoactive mediators leading to renal ischaemia are important in the pathogenesis of acute renal failure. Haemolysis, intravascular coagulation and rhabdomyolysis are important contributing factors. Direct nephrotoxicity can be induced by the venom through metalloproteases and phosphilipase A2. Immunologic mechanism plays a minor role in the pathogenesis of the renal lesion.     

Acute renal failure associated with rhabdomyolysis in acute Q Fever

The clinical presentation of Q fever is polymorphic and non-specific, and it may be presented as an acute or chronic disease. Renal complications of acute Q fever such as acute glomerulonephritis are not uncommon. Acute renal failure induced by rhabdomyolysis in acute Q fever has until now never been reported in the literature. We presented a case of acute Q fever associated by extreme rhabdomyolysis and consecutive acute renal failure. A male patient was treated with doxycycline and continuous venovenous hemodiafiltration. After two weeks of treatment, the patient completely recovered kidney function, and there were no clinical abnormalities. Acute Q fever must be considered as a possible cause of rhabdomyolysis and acute renal failure. The continuous venovenous hemodiafiltration may be effective, and it seems to be the treatment of choice in severe rhabdomyolysis and consecutive acute renal failure.     

Acute renal failure (ARF) caused by rhabdomyolysis due to diabetic hyperosmolar nonketotic coma: a case report and literature review.

We report a case of rhabdomyolysis secondary to diabetic hyperosmolar nonketotic coma leading to acute renal failure. The patient had no overt muscle pain or swelling. Urinary myoglobin was negative. The patient was managed with continuous veno-venous hemodiafiltration (CVVHD) and his renal function subsequently recovered. The clinical features of five other reported cases of rhabdomyolysis caused by diabetic hyperosmolar nonketotic coma in the literature are reviewed.     

Wasp envenomation-induced acute renal failure: a report of three cases

Acute renal failure is an unusual complication of wasp stings. We report three cases who developed acute renal failure after multiple wasp stings (Vespa magnifica). Two patients had evidence of intravascular haemolysis and rhabdomyolysis whereas one patient investigation showed no evidence of intravascular haemolysis or rhabdomyolysis. All three cases had impaired liver functions. Oligo-anuria was seen in all three of the patients and all of them required dialytic support. One patient died of massive gastrointestinal bleeding while the remaining two recovered completely. Although acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of haemolysis or rhabdomyolysis, in some patients, renal failure may result from a direct nephrotoxic effect or acute interstitial nephritis from a hypersensitivity reaction to the wasp venom.     

Rhabdomyolysis and acute renal failure as a complication of urethral surgery

Acute renal failure secondary to rhabdomyolysis is a well-known entity. A case of rhabdomyolysis with renal failure secondary to positioning during urethral surgery is presented.     

SUBARACHNOID HEMORRHAGE AND RHABDOMYOLYSIS INDUCED ACUTE RENAL FAILURE COMPLICATING ORGANOPHOSPHATE INTOXICATION

Organophosphate is extremely uncommon cause of rhabdomyolysis. This article describe two cases with rhabdomyolysis induced acute renal failure complicating by monocrotophos, an organophosphate compound. First patient had rhabdomyolysis induced acute renal failure and subarachnoid hemorrhage. This is the first reported case of subarachnoid hemorrhage, which may be related with organophosphate intoxication in literature. Second patient described here had rhabdomyolysis induced acute renal failure after organophosphate overdose.     

Subarachnoid hemorrhage and rhabdomyolysis induced acute renal failure complicating organophosphate intoxication

Organophosphate is extremely uncommon cause of rhabdomyolysis. This article describe two cases with rhabdomyolysis induced acute renal failure complicating by monocrotophos, an organophosphate compound. First patient had rhabdomyolysis induced acute renal failure and subarachnoid hemorrhage. This is the first reported case of subarachnoid hemorrhage, which may be related with organophosphate intoxication in literature. Second patient described here had rhabdomyolysis induced acute renal failure after organophosphate overdose.     

Acute renal failure due to nontraumatic rhabdomyolysis following binge drinking.

Nontraumatic rhabdomyolysis is an important but under-recognized cause of acute renal failure. In alcoholics, rhabdomyolysis most frequently develop following muscle necrosis during alcohol-induced coma, but has also been described rarely in those without prolonged coma or seizures. We describe a patient who developed myoglobinuric acute renal failure requiring dialysis following binge drinking in the absence of convulsions or coma. The renal biopsy showed acute tubular necrosis with pigment casts.     

Rhabdomyolysis

Key points Rhabdomyolysis describes the destruction or disintegrationof striated muscle; it is an important cause of acute renalfailure. Creatinine kinase concentration is the most sensitiveand useful indicator of muscle injury in rhabdomyolysis. Themost important intervention is early aggressive crystalloidfluid resuscitation. Life-threatening hyperkalaemia is a commoncause of death and must be treated promptly. Myoglobin-inducedrenal failure has an excellent prognosis.   The term rhabdomyolysis describes the breakdown or disintegrationof striated muscle. Although a broad range of conditions canresult in rhabdomyolysis, the final common pathway of myocytenecrosis involves a rapid increase in intracytoplasmic calcium.This leads to the release of myocyte constituents into the circulation,which can produce life-threatening complications including acutehyperkalaemia and acute renal failure (ARF). Rhabdomyolysis is a common cause of ARF, especially in timesof conflict or after major disasters     

Acute tubulointerstitial nephritis after wasp stings

A 61-year-old Caucasian man presented with acute renal failure after multiple wasp stings. The patient required dialysis support temporarily. Work-up failed to show rhabdomyolysis or hemolysis and a kidney biopsy revealed acute allergic interstitial nephritis. The patient's renal function recovered completely after a short course of steroid therapy. Acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of hemolysis or rhabdomyolysis. Compared with previously reported cases of acute renal failure associated with bee stings, our patient is unique in that his renal failure was caused by a hypersensitivity reaction apparently to the wasp venom. © 2001 by the National Kidney Foundation, Inc.     

A case of rhabdomyolysis induced acute renal failure secondary to statin-fibrate-derivative combination and occult hypothyroidism

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle contents into the systemic circulation. We hereby report a patient proved to be a case of unrecognized hypothyroidism presenting with rhabdomyolytic acute renal failure precipitated by the combined use of statin and fenofibrate. A 63-year-old woman was referred to our department because of fatigue, diffuse muscle pain and oliguria. On the basis of pathogenesis, clinical and laboratory examination the diagnoses of acute renal failure secondary to the statin-fibrate-derivative combination induced rhabdomyolysis and auto-immune thyroiditis induced hypothyroidism were made. Although saline, furosemide and sodium bicarbonate infusions enabled diuresis and have led to a rapid recovery of renal function and normalization of blood pressure in five days (creatinine level decreased from 4.5 mg/dl to 1.2 mg/dl), only thyroid replacement therapy (0,1 mg thyroxine) that begun after the exclusion of adrenal insufficiency resulted in complete resolution of rhabdomyolysis. This prompted the diagnosis of background, clinically silent rhabdomyolysis aggrevated by the statin-fibrate-derivative combination. To our knowledge this case illustrates the first example of rhabdomyolytic acute renal failure induced by a statin-fibrate-derivative combination with underlying hypothyroidism which was responsible for the basal clinically unobservable rhabdomyolysis.     

Investigation of etiologies for acute renal failure due to rhabdomyolysis in 5 patients

We experienced 5 cases of acute renal failure due to rhabdomyolysis during the last two years and investigated those etiologies. Diagnosis of rhabdomyolysis was established by the detection of elevated serum creatine phosphokinase, myoglobin, aldolase, myoglobinuria as well as by the clinical course. The respective underlying illness of the 5 cases were grand mal seizures, infection (high fever), heat stroke, diabetes mellitus with hyperosmolar nonketotic coma and cerebral infarction treated by barbiturate. In this investigation, however, any single cause was not enough as the etiologies of rhabdomyolysis. There were multiple factors responsible to rhabdomyolysis in each case, such as hypokalemia, hypophosphatemia, shock, arteriosclerosis, etc. Some cases could not be classified as traumatic or non-traumatic rhabdomyolysis. Thus, in one case, acute renal failure due to rhabdomyolysis induced by the combination of grand mal seizures and serum potassium/phosphate depletion. 2 cases recovered without hemodialysis. 3 cases died in multiple organ failure, included a case treated by hemodialysis. We conclude that acute renal failure due to rhabdomyolysis induced easily by numerous diseases and early diagnosis is recommended.     

Rhabdomyolysis and acute renal failure after terbutaline overdose

A case of rhabdomyolysis-induced acute renal failure secondary to overdosage with the beta 2-adrenoceptor agonist terbutaline is described. This is a previously undocumented association. We propose that the hyperkinetic effects of intense beta-receptor stimulation may induce rhabdomyolysis.     

Severe rhabdomyolysis due to drug overdose

A case of a young girl is described who presented in a state of intoxication and later developed acute renal failure secondary to severe rhabdomyolysis. With vigorous fluid therapy she regained normal renal function. Biochemical testing finally confirmed over the counter drug overdose as the cause for this presentation.     

Renal complications of drug addiction

The kidney is one of the target organs involved as a consequence of the systemic complications seen in drug abusers. This may manifest itself in one of the following forms: acute hepatitis with modest proteinuria (less than 2 Gm. per day); bacterial endocarditis with hematuria, azotemia, and a focal or diffuse glomerulonephritis; the nephrotic syndrome with focal mesangial sclerosis and diffuse interstitial nephritis often pursuing a fulminant course terminating in uremia; acute renal failure secondary to rhabdomyolysis and myoglobinuria; polyarteritis nodosa with renal involvement; and obstructive uropathy secondary to fungus ball in the urinary tract.     

Compartment syndrome,rhabdomyolysis and risk of acute renal failure as complications of the lithotomy position

Compartment syndrome, rhabdomyolysis and the risk of acute renal failure are potential complications of the lithotomy position. A six-year-old girl is described who developed a compartment syndrome with rhabdomyolysis after prolonged surgery in the lithotomy position. This complication occurred three times over ten years in our hospital. Rhabdomyolysis may induce acute renal failure. The pathogenesis of rhabdomyolysis--induced renal failure has not yet been elucidated. However, forced diuresis by intravenous administration of mannitol and furosemide can prevent acute renal failure.