横纹肌溶解症相关急性肾损伤

目的:分析横纹肌溶解症(RM)相关急性肾损伤(AKI)的病因及临床特点。方法:回顾性分析RM引起AKI的病因、临床表现、实验室检查特点并随访观察预后。结果:34例患者诊断为RM相关AKI,其中热射病9例,剧烈运动6例,肌肉受压4例,外伤3例,降脂药物相关3例,甲状腺功能减低2例,毒蛇咬伤2例,黄蜂蛰伤1例,感染2例,重度低钾血症1例,癫痫持续状态1例。34例患者均发生AKI,其中AKI 1期5例,2期5例,3期24例。28例出现少尿、无尿,尿色呈浓茶色或葡萄酒色;8例出现多器官功能障碍综合征。所有患者血清磷酸肌酸激酶、肌红蛋白水平升高,同时伴谷丙/谷草转氨酶、乳酸脱氢酶升高。32例患者磷酸肌酸激酶峰值超过5 000U,19例峰值超过10 000U,但血清肌酸磷酸激酶和肌红蛋白水平与血清肌酐无明显相关性。10例仅行水化及对症治疗,24例行连续性血液净化治疗。3例患者死于多器官衰竭或感染;余31例患者预后良好,出院时均摆脱透析。结论:引起AKI的RM病因多样,其中以热射病和剧烈运动最多见。热射病引起的RM病情危重,常合并多器官功能障碍综合症。连续性血液净化是治疗RM相关的重症AKI的首选,经过积极治疗,多数患者预后良好。     

老年脓毒血症致急性肾损伤患者血清miR210水平及其在病情和预后评估中的价值

目的探讨老年脓毒血症致急性肾损伤(AKI)患者血清miR210水平及其在病情和预后评估中的价值。方法选择104例60岁以上脓毒血症患者,根据是否出现AKI分为AKI组(59例)和非AKI组(45例),并选择同期60岁以上老年健康体检者50例作为对照组(C组)。测定各组血清miR210、胱抑素C、血肌酐、尿N-乙酰-β-D-葡萄糖苷酶(NAG)水平。结果非AKI组和AKI组血清miR210、胱抑素C、血肌酐、尿NAG水平显著高于C组(P<0.05);AKI组血清miR210、胱抑素C、血肌酐、尿NAG水平显著高于非AKI组(P<0.05)。与轻度AKI组比较,重度AKI组血清miR210、胱抑素C、血肌酐、尿NAG水平显著升高(P<0.05)。与AKI存活组比较,AKI死亡组血清miR210、胱抑素C、血肌酐、尿NAG水平显著升高(P<0.05)。AKI组血清miR210与胱抑素C、血肌酐、尿NAG水平呈正相关(P<0.05)。结论老年脓毒血症致AKI患者血清miR210水平升高,血清miR210水平在老年脓毒血症致AKI严重程度、预后评价中具有一定价值。     

草酸性肾病的临床病理特点及预后分析

目的:探讨草酸性肾病的病因、临床病理特点、治疗及预后。方法:回顾性分析2013年1月至2018年4月期间经肾活检确诊为草酸性肾病患者,分析其病因、临床病理特点、治疗及预后。结果:共收集52例草酸性肾病患者男性39例、女性13例,平均年龄49. 4±12. 3岁。49例自体肾,3例移植肾; 2例为原发性高草酸尿症,余50例继发性草酸性肾病,病因包括药物(静脉维生素C最为常见)、摄入富含草酸食物或化学中毒等。最常见的临床表现为少尿/无尿(50. 0%),自体肾表现为急性肾损伤(AKI) 1期、AKI 2期、AKI 3期、慢性肾功能不全基础上出现AKI(ACKD)分别占4. 1%、8. 2%、67. 3%、20. 4%。病程中最高血清肌酐为783. 2±425. 2μmol/L,突出表现为肾小管损伤指标异常,9例行24h草酸定量检测均升高(90. 35±35. 14 mg/24h)。肾脏病理均表现为草酸钙结晶沉积伴急性肾小管间质性损伤。51. 9%的患者接受肾脏替代治疗,以及泼尼松、维生素B6等药物治疗。随访时间12. 1±15. 6月,2例患者进入终末期肾病,33例肾功能恢复正常,恢复时间为56±39d。结论:草酸性肾病的病因多样,继发性草酸性肾病主要病因为药物、高草酸食物和中毒,临床表现为AKI或ACKD,肾活检见草酸钙沉积及肾小管间质急性损伤,半数患者需要肾脏替代治疗,去除诱因并积极治疗后,多数患者肾功能恢复正常。     

急性百草枯中毒患者急性肾损伤的临床特征

目的:急性百草枯中毒引起的急性肾损伤(AKI)发病率较高,但相关研究多限于动物实验,故对百草枯中毒引起AKI认识不足.本研究分析急性百草枯中毒引起AKI的临床特征,进而寻找发生AKI的危险因素,争取做到早发现、早治疗,改善预后.方法:同顾性分析2009年1月～2011年12月中国人民解放军第150中心医院收治的180例急性百草枯中毒患者的症状体征、实验室检查结果、肺部影像学特征及预后.结果:180例急性百草枯中毒患者中98例(54.4％)出现AKI.服毒量＜15 ml及≥15 ml患者AKI发生率分别为13.6％、78.2％,30例(16.7％)出现少尿.98例AKI患者中86例(87.8％)出现蛋白尿和(或)血尿,低分子蛋白尿、管型尿、糖尿、尿NAG升高的发生率分别为84.6％、15.3％、41.8％ 、66.3％.4例经肾活检者肾脏病理改变以肾小球缺血性病变、肾小管间质纤维化为特征.98例百草枯中毒合并AKI的患者死亡率为86.7％.13例存活的AKI患者随访30d,5例血清肌酐波动在123.7 ～247.5μmol/L,2例进展至终末期肾病,余肾功能正常.结论:急性百草枯中毒患者的AKI发生率达54.4％,同时累及肾小球及肾小管,以肾小管间质损害为主;AKI足判断中毒患者病情轻重的指标;早期呕吐、百草枯服用量≥15 ml、服毒至洗胃时间间隔长、血液净化开始时间晚、低氧血症、C反应蛋白升高、外周血白细胞升高、血糖增高是发生AKI的危险因素.     

老年住院患者急性肾损伤病因及预后相关因素分析

目的研究我科老年人急性肾损伤(acute kidney injury,AKI)的发生率、病因构成及预后。方法通过调查2008年我科住院老年(≥60岁)患者肾功能检测结果,筛检出AKI患者,进行复习病史,总结分析患者的临床特征、肾功能受损的性质、导致AKI的基础疾病等。结果共收集患者123例,AKI的发生率占同期老年肾科住院患者的11.28%。肾前性AKI96例(占78.0%),肾实质性AKI20例(占16.3%),肾后性AKI7例(占5.7%)。AKI3期患者衰竭器官数目最多。单因素分析显示,血清白蛋白水平、血红蛋白、衰竭器官数目、血肌酐上升的百分比、血白细胞计数是影响预后的因素。进一步使用logistic回归分析提示器官衰竭数和血肌酐上升百分比是AKI患者死亡的危险因素。结论老年人AKI病因以肾前性所占比例最大,器官衰竭数目和血肌酐上升的百分比(即上升幅度)是影响老年人AKI预后的因素。早期诊断有助于AKI的治愈,提高存活率。     

维持性血液滤过治疗心脏手术后急性肾损伤

目的探讨持续性血液滤过（CVVH）对心脏手术后急性肾损伤（acute kidney injury，AKI）的治疗作用。方法回顾性分析12例心脏手术后AKI患者采用CVVH治疗的临床资料。结果11例存活，1例死亡。存活患者心率及平均动脉压在CVVH过程中波动于正常范围，血肌酐、尿素氮、血钾水平在治疗后显著下降，肾功能均恢复正常。结论CVVH是救治心脏手术后AKI患者的有效手段，此结果仍需扩大样本进一步研究。     

持续低效血液透析滤过治疗老年蜂蜇伤后急性肾损伤的疗效

目的评价持续低效血液透析滤过(SLEDF)对老年蜂蜇伤后急性肾损伤(AKI)患者的治疗价值。方法 40例蜂蜇伤后AKI患者分为非老年血液透析(HD)组,老年HD组和老年SLEDF组。回顾性分析三组患者的临床资料。结果三组患者死亡率差异无统计学意义(P>0.05);与非老年HD组相比,老年HD组痊愈率降低,进入多尿期的时间和血肌酐(Scr)恢复正常的时间延长,血液净化时低血压和心律失常发生率增加(P均<0.05);而与老年HD组相比,老年SLEDF组痊愈率没有差异,进入多尿期的时间和Scr恢复正常的时间缩短,血液净化时低血压和心律失常发生率减少(P<0.01)。结论与HD相比,SLEDF促进老年蜂蜇伤后AKI患者肾功能恢复,降低血液净化时低血压和心律失常发生率。     

尿血管紧张素原早期预测老年脓毒症合并急性肾损伤的临床意义

目的研究尿血管紧张素原早期预测老年脓毒症合并急性肾损伤(AKI)的临床意义。方法选取100例老年脓毒症患者作为研究对象,根据改善全球肾脏病预后组织(KDIGO)的AKI诊断标准将患者分为AKI组和非AKI组,AKI组53例,非AKI组47例,观察测定分析两组在血清肌酐、尿血管紧张素原、尿中性粒细胞明胶酶相关脂质运载蛋白(NGAL)等指标情况及与脓毒症AKI诊断相关性。比较两组治疗前后的各项生活指标评分。结果AKI组各项生物标志物含量均明显高于非AKI组,差异有统计学意义(P<0.05),尿血管紧张素原、血清肌酐、尿NGAL和降钙素原与AKI的发生呈正相关;两组血清肌酐、尿AGT、尿NGAL含量的基线值比较,差异无统计学意义(P均>0.05),非AKI组各指标各个时间段比较差异无统计学意义(P均>0.05),而AKI组各个时间段各指标比较差异有统计学意义(P均<0.05)。血清肌酐在24 h开始上升,尿血管紧张素原在1 h开始上升,尿NGAL在6 h开始上升,尿血管紧张素原的敏感性更高;由受试者工作特征(ROC)曲线分析可得,尿血管紧张素原和尿NGAL敏感性和特异性均优于血肌酐;观察组诊断正确率96.00%,对照组诊断正确率为74.00%,观察组明显高于对照组(χ~2=5.31,P<0.05)。结论尿血管紧张素原联合尿NAGL与脓毒症AKI的诊断相关性高,诊断正确率高,对早期预测脓毒症AKI有很大的测定价值。     

尿NHE3在急性肾损伤早期诊断中的价值

目的探讨尿Na~+/H~+交换体亚型3(Sodium Hydrogen exchanger isoform 3,NHE3)在重症监护(ICU)患者急性肾损伤(acute renal injury,AKI)早期诊断中的价值。方法前瞻性选择入住ICU的100例患者,每天收集血、尿标本,用酶法测定血清肌酐(Scr),ELISA法测定尿NHE3水平,计算肾小球滤过率(GFR),根据有无合并AKI将患者分成AKI组和非AKI组,并与30例健康体检者作为正常对照组进行比较。采用ROC曲线评价尿NHE3诊断AKI的临床价值。结果三组尿NHE3基线水平无明显差异,非AKI组Scr、GFR、尿NHE3水平无明显变化,AKI组尿NHE3水平显著升高,升高时间较Scr提前24 h。尿NHE3与Scr呈正相关、与GFR呈负相关(r=0.457,-0.463,P均0.05)。以Scr升高50%或血肌酐升高绝对值≥26.4μmol/L作为AKI的诊断标准,NHE3灵敏度和特异度绘制ROC曲线,曲线下面积(AUC)为0.758,与完全随机情况下获得的AUC=0.5差异有统计学意义(P0.05)。以NHE3升高50%基础值作为AKI的诊断界限时,敏感度和特异度分别为67.9%和88.9%,阳性预测值和阴性预测值分别为70.4%和87.7%。结论尿NHE3表达较Scr更早发生变化,可作为ICU患者AKI早期预测指标。     

持续性肾脏替代疗法治疗横纹肌溶解征的时机选择

目的:探讨早晚期应用持续性肾脏替代疗法(CRRT)治疗横纹肌溶解征(RM)的临床效果。方法:回顾性分析43例接受CRRT治疗的RM患者的临床资料,根据患者发病到开始进行CRRT治疗的时间分为早期组和晚期组,其中早期组22例,发病起至肌酸磷酸激酶(CPK)升高超过5万U/L或者较入院时升高3倍以上时行CRRT治疗;晚期组21例,发病起至出现急性肾损伤(AKI)时行CRRT治疗。比较其治疗前、后的血肌红蛋白(Mb)、CPK、肌酐(SCr)、尿素氮(BUN)等指标和急性生理与慢性健康评分(APACHEⅡ)的变化,探讨应用CRRT治疗RM的时机及对预后的影响。结果:早期组的死亡率和平均住院日均明显低于晚期组[9. 1%vs 33. 3%;(18. 5±5. 8) d vs(27. 8±4. 7) d,均P 0. 05];经过CRRT治疗后,早期组血Mb、CPK、SCr、BUN等各指标亦明显低于晚期组(P 0. 05)。结论:早期CRRT治疗RM效果更显著。     

Clinical Features of and Risk Factors for Rhabdomyolysis Among Adult Patients with Dengue Virus Infection

Among 1,076 dengue patients, 9 patients with rhabdomyolysis and 1,067 patients without rhabdomyolysis (controls) were retrospectively analyzed. Of nine patients with rhabdomyolysis, the most commonly reported symptom other than fever was myalgia; dengue hemorrhagic fever (DHF) was found in seven cases, and acute kidney injury was found in six cases. Furthermore, one (11.1%) patient died. The median duration from hospital admission to rhabdomyolysis diagnosis was 3 days. Patients with rhabdomyolysis had higher age, proportion of men, prevalence of hypertension, frequency of myalgia, and incidences of DHF, pleural effusion, and acute kidney injury than controls. Multivariate analysis showed that hypertension (odds ratio [OR] = 14.270), myalgia (OR = 20.377), and acute kidney injury (OR = 65.547) were independent risk factors for rhabdomyolysis. Comparison of cytokine/chemokine concentrations in 101 DHF patients, including those with (N = 4) and without (N = 97) rhabdomyolysis, showed that interleukin-6 and tumor necrosis factor-α levels were significantly increased in the former.     

Serum cystatin C versus serum creatinine in the estimation of glomerular filtration rate in rhabdomyolysis

Cystatin C has emerged as a possible, usable surrogate marker of renal function. We present a case that illustrates the clinical utility of cystatin C in the setting of acute kidney injury secondary to rhabdomyolysis. An African American male whose baseline cystatin C and serum creatinine levels taken a month prior to admission were compared against their daily values during his admission and at follow up. On admission, the patient's reduction in glomerular filtration rate (GFR) from baseline was much less when calculated with cystatin C than with serum creatinine. His clinical recovery was more reflective of the higher GFR with cystatin C than what would be assumed with his serum creatinine, which at its worst was 5 ml/min/1.73 m(2). The patient was eventually discharged from the hospital with a GFR of 40 ml/min by cystatin C despite his GFR by the MDRD equation being 12. Cystatin C may be a more accurate marker of the both the amount of injury and the rate of resolution of acute kidney injury than serum creatinine in rhabdomyolysis.     

Acute rhabdomyolysis and renal failure in HIV-infected patients: risk factors, presentation, and pathophysiology

Rhabdomyolysis is a common cause of acute renal failure and may be related to a variety of predisposing factors. This entity has been increasingly recognized in HIV-infected individuals and is an important cause of morbidity and mortality. We present a series of seven HIV-positive patients admitted with rhabdomyolysis over a 5-year period; three developed acute renal failure. Infections and substance abuse were the most common risk factors identified; an average of three predisposing factors was present in each case. All patients showed resolution of creatinine phosphokinase (CPK) elevation and serum creatinine returned to the normal range in the three patients who developed renal insufficiency; however, all patients required prolonged hospitalization and one patient died of sepsis. The pathophysiological mechanisms of muscle injury in our patients are reviewed and their bearing on prognosis discussed. It is concluded that clinicians should have a high index of suspicion for the development of rhabdomyolysis in HIV-infected patients with a combination of noncompliance with medical therapy and/or substance abuse and acute infection. With comprehensive supportive care, the prognosis of acute rhabdomyolysis in this population may be reasonably good.     

Clinical evaluation of pneumonia-associated rhabdomyolysis with acute renal failure

This study aims to evaluate the clinical features, diagnosis, and treatment efficacy in patients with pneumonia-associated rhabdomyolysis and acute renal failure. The subjects included six patients who had presented with rhabdomyolysis and acute renal failure due to bacterial or viral pneumonia on admission to our university hospital and the Yokohama Social Insurance Central Hospital between 2004 and 2005. The causative organisms were identified as Legionella pneumophila (N = 1), Staphylococcus epidermidis (N = 2), Staphylococcus aureus (N = 1), and Unknown (N = 2). For anuric or oliguric patients (N = 4), a blood purification therapy was performed, while conservative therapy was administered to those with a normal urine volume (N = 2). The patient suffering from L. pneumophila pneumonia did not survive, while the other patients regained full kidney function. It is important to identify, evaluate, and treat patients with bacterial or viral pneumonia-associated rhabdomyolysis and acute renal failure.     

Rhabdomyolysis and unilateral renal infarction after a motor vehicle crash

A 46-year-old man with no previous history of abnormal urinalysis findings or renal dysfunction was admitted to a local hospital because of a motor vehicle crash. An open laparotomy was performed to treat a perforation of the small intestine. After operation, oliguria and renal dysfunction developed, and he was admitted to our hospital because of acute renal failure after trauma. Acute renal failure was assumed to be due to rhabdomyolysis with elevated serum creatinine, blood urea nitrogen, and creatine kinase levels and myoglobinemia. Left flank pain occurred several days after admission, and the serum alkaline phosphatase level increased between days 5 and 12 following admission. Although hemodialysis was performed 9 times and the urine output was satisfactory, the creatinine clearance levels increased only to about 50 mL/min/1.73 m2 (0.84 mL/s/m2) at 6 weeks following admission. As a result, a diagnosis of renal infarction due to acute renal artery occlusion was considered. The left kidney was atrophic on an abdominal computed tomographic scan and was nonfunctioning on a renogram. This case shows the importance of not overlooking the possibility of a renal infarction associated with rhabdomyolysis after a motor vehicle crash. In particular, the changes in the serum alkaline phosphatase levels were important in making a correct diagnosis in this case.     

Occult elevation of CK as a manifestation of rhabdomyolysis in the elderly.

OBJECTIVE: To evaluate the incidence, etiology and clinical course of rhabdomyolysis in hospitalized elderly patients. DESIGN: Retrospective case series. SETTING: Acute geriatric department of a university-affiliated teaching hospital. PATIENTS: Twenty-three patients who fulfilled our criteria of rhabdomyolysis. Criteria for inclusion were the finding of elevated serum creatine kinase of five-fold or greater above the upper reference limit and greater than 97% MM isoenzyme. RESULTS: In a 3-year period 23 patients out of 2,870 admissions fulfilled the criteria for rhabdomyolysis, an incidence rate of 0.8%. Diseases or insults associated with rhabdomyolysis were, in order of frequency, acute immobilization, infectious disease, cerebrovascular accident, hyperosmolar state, hyponatremia, hypernatremia, hypothermia, and a fall. Twenty-two patients recovered from the acute illness; one patient died from respiratory failure. Seventeen patients had renal failure (serum creatinine greater than 180 mumol/L), none necessitating dialysis. Serum creatinine always declined following recovery. CONCLUSION: Elevation of CK with few other clinical features of rhabdomyolysis is common in admissions to a geriatric service. It is due to complete immobilization resulting from acute illness. Renal failure is mild and reversible, and the prognosis for recovery is excellent.     

Rhabdomyolysis: an evaluation of 475 hospitalized patients

Rhabdomyolysis is a common and potentially lethal clinical syndrome that results from acute muscle fiber necrosis with leakage of muscle constituents into blood. Myoglobinuria is the most significant consequence, leading to acute renal failure (ARF) in 15%-33% of patients with rhabdomyolysis. Rhabdomyolysis occurs from inherited diseases, toxins, muscle compression or overexertion, or inflammatory processes, among other disorders. In some cases, no cause is found.We describe 475 patients from the Johns Hopkins Hospital inpatient records between January 1993 and December 2001 for the following discharge diagnosis codes: myoglobinuria, rhabdomyolysis, myopathy, toxic myopathy, malignant hyperthermia, neuroleptic malignant syndrome, and polymyositis. Of 1362 patients, 475 patients with an acute neuromuscular illness with serum creatine kinase (CK) more than 5 times the upper limit of normal (>975 IU/L) were included. Patients with recent myocardial infarction or stroke were excluded. The etiology was assigned by chart review. For all, the highest values of serum CK, serum creatinine and urine myoglobin, hemoglobin, and red blood cells were recorded. Forty-one patients had muscle biopsy within at least 2 months from the onset of rhabdomyolysis.Of the 475 patients, 151 were female and 324 were male (median age, 47 yr; range, 4-95 yr). Exogenous toxins were the most common cause of rhabdomyolysis, with illicit drugs, alcohol, and prescribed drugs responsible for 46%. Among the medical drugs, antipsychotics, statins, zidovudine, colchicine, selective serotonin reuptake inhibitors, and lithium were the most frequently involved. In 60% of all cases, multiple factors were present. In 11% of all cases, rhabdomyolysis was recurrent. Underlying myopathy or muscle metabolic defects were responsible for 10% of cases, in which there was a high percentage of recurrence, only 1 etiologic factor, and a low incidence of ARF. In 7%, no cause was found. ARF was present in 218 (46%) patients, and 16 died (3.4%). A linear correlation was found between CK and creatinine and between multiple factors and ARF, but there was no correlation between ARF and death or between multiple factors and death. Urine myoglobin detected by dipstick/ultrafiltration was positive in only 19%.Toxins are the most frequent cause of rhabdomyolysis, but in most cases more than 1 etiologic factor was present. Patients using illicit drugs or on prescribed polytherapy are at risk for rhabdomyolysis. The absence of urine myoglobin, by qualitative assay, does not exclude rhabdomyolysis. With appropriate care, death is rare.     

A case of primary human immunodeficiency virus infection with severe rhabdomyolysis without acute renal failure

Subjects with primary human immunodeficiency virus (HIV) infection often have acute retroviral syndrome. Some develop rhabdomyolysis, which can lead to acute renal failure. A 21-year-old man admitted for consciousness disturbance was initially considered to have aseptic meningitis associated with primary HIV infection. On hospitalization day 3, he developed severe rhabdomyolysis with elevated serum creatine kinase (CK) of 218,100 IU/L with serum creatinine normal at 0.9 mg/dL. Following massive extracellular fluid infusion and urinary alkalinization, serum CK decreased smoothly, without renal failure. Severe rhabdomyolysis was concomitant with systemic inflammatory response syndrome (SIRS) only on admission day. Acute renal failure in those with rhabdomyolysis may be influenced by renal possibly due to SIRS and tubular damage from reactive oxygen species, rather than by tubular obstruction by myoglobin casts, although this depends on the extent of myolysis. Acute renal failure is prevented in those with primary HIV infection developing rhabdomyolysis, based on renal blood flow control, if condition causing SIRS do not become a complication.     

107例小龙虾致横纹肌溶解综合征病例分析

<正>横纹肌溶解综合征(rhabdomyolysis,RM)是一组由于各种原因所引起的骨骼肌损伤,细胞膜完整性改变,细胞内容物释放入血液中所引起的临床综合征,常伴有代谢紊乱和急性肾衰竭等一系列并发症~[1]。其临床主要表现为肌肉疼痛、肿胀、无力、酱油色尿等。由于肌细胞的坏死和分解,细胞内容物如Mb、CPK、电解质、蛋白质和非蛋白物质被释放进入血浆,因此,这些物质的检测有助于RM的早期诊断~[2]。本文对107例因进食小龙虾所引起的RM病