The value of serum creatine kinase in predicting the risk of rhabdomyolysis-induced acute kidney injury: a systematic review and meta-analysis

Traumatic rhabdomyolysis: rare but morbid, potentially lethal, and inconsistently monitored

PURPOSE

Although traumatic rhabdomyolysis (TR) is shown to be associated with acute kidney injury (AKI), there are no large prospective epidemiological studies, interventional trials, official guidelines outlining the appropriate investigation, monitoring, and treatment on this poorly understood condition. We aimed to establish the contemporary epidemiology and describe current practices for TR to power future higher quality studies. We hypothesised that investigation and monitoring occur in an ad hoc fashion.

MATERIAL AND METHODS

We conducted a 1-year retrospective cohort study of all patients > 16 years of age, with an ISS > 12 and, admitted to a level 1 trauma centre. Demographics, initial vital signs, admission laboratory values, and daily creatinine kinase (CK) values were collected. The primary outcome was TR (defined by CK > 5000 IU), secondary outcomes included AKI (KDIGO criteria), mortality, multiple organ failure, length of stay, and need for renal replacement therapy (RRT).

RESULTS

586 patients met inclusion criteria and 15 patients (2.56%) developed TR. CK testing occurred in 78 (13.1%) patients with 29 (37.7%) of these having values followed until downtrending. AKI occurred in 63 (10.8%) patients within the entire study population. Among those with TR, nine (60%) patients developed AKI. Patients with TR had higher ISS (median 29 vs 18) and mortality (26.7% vs 8.9%).

DISCUSSION

Whilst TR appears rare without liberal screening, it is strongly associated with AKI. Given the poor outcomes, standardised monitoring, and liberal testing of CK could be justified in trauma patients with higher injury severity. This epidemiological data can help to define study populations and power future multicentre prospective studies on this infrequent yet morbid condition.

The effects of inspiratory muscle training on swimming performance: A study on the cohort of swimming specialization students

PURPOSE

Current evidence posits a strong correlation between respiratory muscle function and swimming performance. Despite this, few studies have explored the integration of inspiratory muscle training (IMT) into standard swimming training regimens, which remains an unexplored avenue for improving performance in swimmers. This study aims to evaluate the potential advantages of IMT for enhancing respiratory function and swimming performance and determine whether such training could induce beneficial physiological adaptations.

METHODS

We designed and conducted a randomized controlled trial involving 43 swimming specialization students aged 18-25 years. Participants were randomly allocated to two groups: a control group, which followed regular swimming training, and an experimental group, which complemented the standard training with IMT. The intervention lasted for six weeks. Key outcomes measured included swimming performance metrics (time of 50 m freestyle, number of breaths in 50 m freestyle, distance before first breath in freestyle, time of 100 m freestyle) and various inspiratory muscle function parameters such as vital capacity (VC), maximum inspiratory pressure (MIP), maximum inspiratory flow (MIF), and maximum inspiratory capacity (MIC). We also assessed certain biochemical parameters, including hemoglobin, creatine kinase (CK), blood urea nitrogen (BUN), testosterone, and cortisol concentrations.

RESULTS

Following the training period, the experimental group exhibited significant improvements in swimming performance and respiratory function parameters. We also noted an increase in hemoglobin levels and a reduction in testosterone concentrations in this group, suggesting beneficial physiological adaptations in response to the combined IMT and swimming training.

CONCLUSION

Our findings underline the potential of IMT as a supplementary training modality for enhancing respiratory function and improving swimming performance. The changes in biochemical parameters suggest physiological adaptations that might contribute to these observed improvements. This study opens the door for future research on the benefits of integrating IMT into training regimens for competitive swimmers. Further investigation is warranted to fully elucidate the mechanisms behind the observed benefits and to validate these findings in a larger cohort and other athlete populations.

Clinical and Epidemiological Characteristics of Rhabdomyolysis: A Retrospective Study

Background

Rhabdomyolysis (RM) refers to a clinical syndrome in which muscle cells are damaged by various causes and the clinical manifestations are mainly muscle pain, weakness, and dark urine. Acute kidney injury (AKI) is a serious complication of RM with complex mechanisms and high mortality. Therefore, understanding the pathogenesis and clinical manifestations, early diagnosis and treatment of RM are crucial to improve its prognosis.

Method

Analysis of medical records of RM patients admitted to Tianjin Medical University General Hospital from October 2019 to October 2022. Statistical software SPSS 25.0 was used to analyze the data. The risk factors of RM-complicated AKI were analyzed by logistic regression. The receiver operating characteristic (ROC) curve was plotted, the area under the curve (AUC) was calculated, and the optimal cutoff value was determined by the Youden index. P < 0.05 indicates a statistically significant difference between the groups.

Result

Among the 71 patients, the median age of the patients was 53.0 (30.0, 71.0) years and was 2.5 times higher in men than in women. Infection was the most common etiology. History of alcohol consumption, CK, and creatinine were independent influencing factors for AKI due to RM. Logistic regression analysis showed that CK combined with creatinine had a better predictive value than the single index.

Conclusion

Our study revealed the clinical and laboratory characteristics of RM in the population attending the Tianjin Medical University General Hospital in the last three years, which is a reference for future multicenter, prospective studies.

Progress in the Diagnostic and Predictive Evaluation of Crush Syndrome

Crush syndrome (CS), also known as traumatic rhabdomyolysis, is a syndrome with a wide clinical spectrum; it is caused by external compression, which often occurs in earthquakes, wars, and traffic accidents, especially in large-scale disasters. Crush syndrome is the second leading cause of death after direct trauma in earthquakes. A series of clinical complications caused by crush syndrome, including hyperkalemia, myoglobinuria, and, in particular, acute kidney injury (AKI), is the main cause of death in crush syndrome. The early diagnosis of crush syndrome, the correct evaluation of its severity, and accurate predictions of a poor prognosis can provide personalized suggestions for rescuers to carry out early treatments and reduce mortality. This review summarizes various methods for the diagnostic and predictive evaluation of crush syndrome, including urine dipstick tests for a large number of victims, traditional and emerging biomarkers, imaging-assisted diagnostic methods, and developed evaluation models, with the aim of providing materials for scholars in this research field.

Postoperative rhabdomyolysis following otoplasty: an autopsy case report

Postoperative rhabdomyolysis is a significant complication that can arise from prolonged surgery, causing potential harm to the kidneys and leading to acute renal failure. Despite its importance, the incidence of rhabdomyolysis following ear reconstruction surgery remains undocumented in the literature. In this report, we present a case study of a male patient in his forties who underwent otoplasty for ear reconstruction after the amputation of his right ear due to a physical assault. The surgery lasted for 8 h under general anesthesia, and unfortunately, the patient developed postoperative rhabdomyolysis, which resulted in severe renal failure and ultimately an unrecoverable cardiac arrest, leading to his death. The autopsy findings indicated no identifiable lesions except for organ congestion, while histopathology revealed acute tubular necrosis of the kidney and muscle rhabdomyolysis. Previous literature has explored the association between surgical duration, location, and rhabdomyolysis, underscoring that this condition is an infrequent yet preventable consequence of prolonged surgery. The co-occurrence of rhabdomyolysis and acute renal injury in this case suggests the presence of comorbidity, emphasizing the need for prompt action to mitigate the negative consequences of rhabdomyolysis. Awareness and early intervention are crucial in preventing and managing this condition effectively.

Severe pathological changes in the blood and organs of SD rats stung by honeybees

With the development of beekeeping, the risk of bee stings in humans is increasing. Severe and life-threatening toxic reactions can occur after multiple bee stings, and their pathogenesis has not been elucidated. To understand the effect of multiple bees (Apis mellifera) stings on the organism in a short period, we stung rats once and five times, respectively. Serum and organs were obtained after 3 h for analysis. The results indicated that skin erythema was more pronounced and hemolysis was more severe as the number of puncture wounds increased. After being stung by five bees, rats had dramatically higher serum levels of direct bilirubin, aspartate aminotransferase, creatine kinase and lactate dehydrogenase, producing more differential metabolites that affected mainly four metabolic pathways. In addition, the liver, kidney and heart showed significant congestion and inflammation. This study helps explain the organism's clinical response to bee venom and may be valuable in treating toxic reactions following bee stings.

Effects of Epothilone Administration on Locomotion Recovery after Spinal Cord Injury: A Systematic Review of Animal Studies

This is a systematic review and meta-analysis of existing evidence regarding the possible effects of epothilones on spinal cord injury (SCI). This study aimed to investigate the possible effects of epothilone administration on locomotion recovery in animal models of SCI. Despite increasing rates of SCI and its burden on populations, no consensus has been reached about the possible treatment modality for SCI. Meanwhile, low-dose epothilones have been reported to have positive effects on SCI outcomes. Electronic databases of Web of Science, Scopus, Embase, and Medline were searched using keywords related to epothilones and SCI until the end of 2020. Two researchers screened the articles, and extracted data were analyzed using STATA ver. 14.0. Final results are reported as a standardized mean difference (SMD) with a 95% confidence interval (CI). After the screening, five studies were included in the analysis. Rats were used in all the studies. Two types of epothilones were used via intraperitoneal injection and were shown to have positive effects on the motor outcomes of samples with SCI (SMD, 0.87; 95% CI, 0.51 to 1.23; p =0.71). Although a slightly better effect was observed when using epothilone B, the difference was not significant (coefficient, -0.50; 95% CI, -1.52 to 0.52; p =0.246). The results of this study suggest that epothilones have positive effects on the improvement of motor function in rats, when administered intraperitoneally until a maximum of 1 day after SCI. However, current evidence regarding the matter is still scarce.

Extremely elevated creatine kinase associated with rhabdomyolysis-induced acute kidney injury in a patient with Huntington's disease: a case report

BACKGROUND

Rhabdomyolysis-induced acute kidney injury is a serious condition that can progress to acute renal failure if not promptly identified and treated. Rhabdomyolysis occurs when serum creatine kinase levels approach > 1000 U/L (five times the normal upper limit). The chance of acute kidney injury increases as the levels of creatine kinase increase. Although Huntington's disease is associated with muscle atrophy, elevated baseline creatine kinase levels in these patients have not been routinely reported.

CASE PRESENTATION

A 31-year-old African American patient presented to the emergency department after he was found unconscious from a fall attributed to the progression of his Huntington's disease. On admission, he had an extremely high creatine kinase level of 114,400 U/L and was treated with fluids, electrolyte balance, and dialysis. However, his condition progressed to acute renal failure and he later developed posterior reversible encephalopathy syndrome, requiring transfer to the intensive care unit with placement on continuous renal replacement therapy. Eventually, his kidney function recovered and he was discharged home with 24/7 care by his family for persistent impairments related to his Huntington's disease.

CONCLUSIONS

This case report underscores the importance of promptly recognizing elevated creatine kinase levels in patients with Huntington's disease due to the risk of developing rhabdomyolysis-induced acute kidney injury. If not aggressively treated, the condition of these patients is likely to progress to renal failure. Anticipating the progression of rhabdomyolysis-induced acute kidney injury is paramount to improving clinical outcomes. Additionally, this case identifies a potential link between the patient's Huntington's disease and his abnormally elevated creatine kinase, a finding not described in the literature of rhabdomyolysis-induced kidney injuries to date and an important consideration for future patients with similar comorbidities.

Predictors of acute kidney injury in patients after extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared with conventional CPR. Data after eCPR for acute kidney injury (AKI) are lacking. We sought to investigate factors predicting AKI in patients who underwent eCPR.

METHODS

From January 2016 until December 2020, patients who underwent eCPR at our institution were retrospectively analyzed and divided into two groups: patients who developed AKI (n = 60) and patients who did not develop AKI (n = 35) and analyzed for outcome parameters.

RESULTS

Overall, 63% of patients suffered AKI after eCPR and 45% of patients who developed AKI needed subsequent dialysis. Patients who developed AKI showed higher values of creatinine (1.1 mg/dL vs 1.5 mg/dL, p ⩽ 0.01), urea (34 mg/dL vs 42 mg/dL, p = 0.04), CK (creatine kinase) (923 U/L vs 1707 U/L, p = 0.07) on admission, and CK after 24 hours of ECMO support (1705 U/L vs 4430 U/L, p = 0.01). ECMO explantation was significantly more often performed in patients who suffered AKI (24% vs 48%, p = 0.01). In-hospital mortality (86% vs 70%; p = 0.07) did not differ significantly.

CONCLUSION

Patients after eCPR are at high risk for AKI, comparable to those after conventional CPR. Baseline urea levels predict the development of AKI during the hospital stay.

Case report: Rhabdomyolysis in children in acute and chronic disease-a challenging condition in pediatric emergency medicine

Rhabdomyolysis is a challenging condition in pediatric emergency departments (PED): It ranges from asymptomatic illness with isolated elevation of creatine kinase (CK) levels to a life-threatening condition associated with extreme elevations in CK, electrolyte imbalances, circulatory failure (CF), acute kidney injury (AKI), and multi-organ disease. Most common causes of rhabdomyolysis are viral myositis and trauma, hereditary metabolic myopathies must be considered when facing rhabdomyolysis in early childhood. We report two cases of severe rhabdomyolysis with CF in our PED, thereby summarizing first-line management of rhabdomyolysis.

Motor Vehicle Collision and Acute Kidney Injury in Children

OBJECTIVE

Our study aimed to determine the prevalence of acute kidney injury (AKI) in pediatric patients who sustained trauma due to motor vehicle collision (MVC) and identify factors associated with its development.

METHODS

We retrospectively reviewed the clinical information and laboratory tests of pediatric patients who were admitted because of MVC from January 2014 to April 2021. The occurrence of AKI was our primary outcome, which was defined by the Kidney Disease Improving Global Outcomes criteria. A serum creatine kinase (CK) level of 1000 IU/L or greater was defined as rhabdomyolysis.

RESULTS

Sixty-four patients (median age, 9.6 years) were included in the study. Twenty three of the patients (35.9%) developed AKI: stage 1 AKI in 18 (78.3%) and stage 2 AKI in 5 (21.7%) patients. Acute kidney injury patients had higher injury severity scores (no AKI: 5.0; stage 1 AKI: 10.5; stage 2 AKI: 26.0). Rhabdomyolysis was present in 21.1% of the patients and was associated with the overall AKI risk (odds ratio [OR], 7.3; 95% confidence interval [CI], 1.6-32.6) and stage 2 AKI (OR, 15.0; 95% CI, 1.4-163.2). Blood tests from AKI patients showed lower serum bicarbonate and base excess, higher leukocyte and CK levels on admission, and a higher peak CK in the first 72 hours of admission. Intubation in emergency department (OR, 11.1; 95% CI, 1.2-102.1) and surgical interventions (OR, 3.2; 95% CI, 1.0-9.8) were associated with AKI. Acute kidney injury patients required longer stay in pediatric intensive care unit (median 1.0 vs 2.3 days, P < 0.001) and hospital (median 4.1 vs 7.0 days, P = 0.010).

CONCLUSIONS

Approximately one third of pediatric patients who sustained trauma from MVC developed AKI. Initial blood results, including higher CK and leukocyte count, and lower bicarbonate and base excess, were associated with the development of AKI. Rhabdomyolysis occurred in approximately one fifth of the patients and was significantly associated with AKI.

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.

Extreme Elevation of Creatine Kinase in a Young Male Patient With Recurrent Rhabdomyolysis

Rhabdomyolysis is a common cause of admission to the intensive care unit. However, recurrent rhabdomyolysis remains a rare encounter for intensivists and presents a challenge in terms of identifying its etiology. Considerations of metabolic myopathies as a culprit remain underexplored. We present a case of a patient with recurrent rhabdomyolysis with extreme elevation of creatine kinase.

Psychosis-Induced Exertional Rhabdomyolysis without Acute Kidney Injury or Myoglobinuria

Patient: Male, 21-year-old

Final Diagnosis: Rhabdomyolysis

Symptoms: Myalgia • psychosis

Medication: —

Clinical Procedure: Intravenous hydration

Specialty: General and Internal Medicine

Serum myoglobin as predictor of acute kidney injury and 90-day mortality in patients with rhabdomyolysis after exertional heatstroke: an over 10-year intensive care survey

OBJECTIVE

Rhabdomyolysis (RM) in exertional heatstroke (EHS) often leads to multiple organ dysfunction including acute kidney injury (AKI). Studies have shown that serum creatine kinase (CK) >1000 U/L as a serological diagnostic criterion for RM does not reflect the risk of AKI or mortality.

METHODS

This longitudinal cohort study included all patients with EHS who were admitted to intensive care unit between January 2008 and June 2019. Serum myoglobin (sMb) was studied as the serological marker of RM and compared with CK. Outcome events were AKI and 90-day mortality.

RESULTS

A total of 161 patients were enrolled, of whom 52 (32.3%) had sMb ≥1000 ng/mL. Patients with sMb ≥1000 ng/mL had higher SOFA score, higher APACHE II score, lower GCS score, and higher incidence of disseminated intravascular coagulation, acute myocardial injury, acute liver injury, AKI, and 90-day mortality than patients with sMb <1000 ng/mL. Lymphocytes, neutrophils, D-Dimer were risk factors for AKI in patients with sMb ≥1000 ng/mL. Curve fitting showed a curved relationship between sMb and EHS-induced AKI but not CK. sMb ≥1000 ng/mL showed better predictive ability for AKI (area under curve: 0.786). APACHE II, SOFA, and GCS scores were risk factors for 90-day mortality in patients with sMb ≥1000 ng/mL.

CONCLUSION

Serum myoglobin is a better predictor of AKI and 90-day mortality than CK in patients with RM after EHS.

Acute Kidney Injury following Rhabdomyolysis in Critically Ill Patients

Introduction

Rhabdomyolysis, which resulted from the rapid breakdown of damaged skeletal muscle, potentially leads to acute kidney injury.

Aim

To determine the incidence and associated risk of kidney injury following rhabdomyolysis in critically ill patients.

Methods

All critically ill patients admitted from January 2016 to December 2017 were screened. A creatinine kinase level of > 5 times the upper limit of normal (> 1000 U/L) was defined as rhabdomyolysis, and kidney injury was determined based on the Kidney Disease Improving Global Outcome (KDIGO) score. In addition, trauma, prolonged surgery, sepsis, antipsychotic drugs, hyperthermia were included as risk factors for kidney injury.

Results

Out of 1620 admissions, 149 (9.2%) were identified as having rhabdomyolysis and 54 (36.2%) developed kidney injury. Acute kidney injury, by and large, was related to rhabdomyolysis followed a prolonged surgery (18.7%), sepsis (50.0%) or trauma (31.5%). The reduction in the creatinine kinase levels following hydration treatment was statistically significant in the non- kidney injury group (Z= -3.948, p<0.05) compared to the kidney injury group (Z= -0.623, p=0.534). Significantly, odds of developing acute kidney injury were 1.040 (p<0.001) for mean BW >50kg, 1.372(p<0.001) for SOFA Score >2, 5.333 (p<0.001) for sepsis and the multivariate regression analysis showed that SOFA scores >2 (p<0.001), BW >50kg (p=0.016) and sepsis (p<0.05) were independent risk factors. The overall mortality due to rhabdomyolysis was 15.4% (23/149), with significantly higher incidences of mortality in the kidney injury group (35.2%) vs the non- kidney injury (3.5%) [ p<0.001].

Conclusions

One-third of rhabdomyolysis patients developed acute kidney injury with a significantly high mortality rate. Sepsis was a prominent cause of acute kidney injury. Both sepsis and a SOFA score >2 were significant independent risk factors.

Admission serum myoglobin and the development of acute kidney injury after major trauma

BACKGROUND

Myoglobin and creatine kinase (CK) are both established markers of muscle injury but their hospital admission values have never been compared to predict post-traumatic acute kidney injury (AKI).

METHODS

An observational registry study of consecutive trauma patients admitted to a major regional trauma centre. The primary outcome was stage 1 or more AKI in the first 7 days after trauma. We assessed the association of hospital admission myoglobin or CK with development of AKI both alone and when added to two existing risk prediction models for post traumatic AKI.

RESULTS

Of the 857 trauma patients (median age 36 [25-52], 96% blunt trauma, median ISS of 20 [12-47]) included, 102 (12%) developed AKI. Admission myoglobin performed better than CK to predict AKI any stage with an AUC-ROC of 0.74 (95% CI 0.68-0.79) and 0.63 (95% CI 0.57-0.69), respectively (p < 0.001). Admission myoglobin also performed better than CK to predict AKI stage 2 or 3 [AUC-ROC of 0.79 (95% CI 0.74-0.84) and 0.74 (95% CI 0.69-0.79), respectively (p < 0.001)] with a best cutoff value of 1217 µg/L (sensitivity 74%, specificity 77%). Admission myoglobin added predictive value to two established models of AKI prediction and showed significant ability to reclassify subjects regarding AKI status, while admission CK did not. Decision curve analysis also revealed that myoglobin added net benefit to established predictive models. Admission myoglobin was better than CK at predicting development of significant rhabdomyolysis.

CONCLUSIONS

Admission myoglobin better predicts the development of AKI and severe rhabdomyolysis after major trauma. Admission myoglobin should be added in established predictive models of post-traumatic AKI to early identify high-risk patients.

Guidelines for the acute care of severe limb trauma patients

GOAL

To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre.

DESIGN

A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded.

METHODS

The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

Aetiologies and factors associated with poor clinical outcomes in rhabdomyolysis: a retrospective cohort study in an Australian trauma centre

Rhabdomyolysis is a clinical syndrome with significant morbidity and mortality that occurs as a result of traumatic and non-traumatic aetiologies. Acute kidney injury, the need for dialysis, and death, can occur due to rhabdomyolysis. This study explores the aetiologies, clinical outcomes and associated factors for poor outcomes in a cohort of patients with rhabdomyolysis in a tertiary trauma centre in Australia.

Epidemiology and the Impact of Acute Kidney Injury on Outcomes in Patients with Rhabdomyolysis

Background: Currently, no large, nationwide studies have been conducted to analyze the demographic factors, underlying comorbidities, clinical outcomes, and health care utilization in rhabdomyolysis patients with and without acute kidney injury (AKI). Methods: We queried the National Inpatient Sample of Healthcare Cost and Utilization Project (HCUP) with patients with rhabdomyolysis from 2016 to 2018. The chi-squared test was used to compare categorical variables, and the adjusted Wald test was employed to compare quantitative variables. The logistic regression model was applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) to estimate the impact of AKI on outcomes in patients with rhabdomyolysis. Results: Among 111,085 rhabdomyolysis-related hospitalizations, a higher prevalence of AKI was noticed in older patients (mean age ± SD, 58.2 ± 21.6 vs. 53.8 ± 22.2), Medicare insurance (48.5% vs. 43.2%), and patients with a higher Charlson Comorbidity Index score (CCI 3–5, 15.1% vs. 5.5%). AKI was found to be independently associated with higher mortality (adjusted odds ratio [aOR] 3.33, 95% CI 2.33–4.75), longer hospital stays (adjusted difference 1.17 days, 95% CI: 1.00−1.34), and higher cost of hospital stay (adjusted difference $11,315.05, 95% CI: $9493.02–$13,137.07). Conclusions: AKI in patients hospitalized with rhabdomyolysis is related to adverse clinical outcomes and significant economic and survival burden.

Acute viral myositis: profound rhabdomyolysis without acute kidney injury

Background

Acute viral myositis (AVM) may be triggered by influenza A/B, enteroviruses and other viruses. Severe complications including rhabdomyolysis regularly lead to acute kidney injury (AKI). The aim of this short report was to discuss management and differential diagnosis of massive creatine kinase (CK) elevation.

Patient, material and methods

Herein, we report on a 19-year-old Austrian male of African descent with a history of respiratory tract infections and whole-body pain. He further developed acute viral myositis and massive CK elevation up to 440,000 IU/L but without any signs of AKI. A literature search relating AVM, management and differential diagnosis of rhabdomyolysis was conducted in PubMed and UptoDate.

Results

A full panel of serological and autoimmune blood work-up including testing for human immunodeficiency virus (HIV), hepatitis, influenza A/B, Epstein-Barr virus (EBV), antinuclear antibodies (ANA) and autoantibodies against various extractable nuclear antigens (ENA) did not reveal evidence for viral originators or autoimmune diseases. This case indicates that in acute viral myositis associated with extreme CK elevation (>400,000 IU/L) AKI might be completely absent. Potential causes for this clinical phenotype, differential diagnosis and management are discussed.

Postoperative extremity compartment syndrome in a cancer center: Incidence and risk factors

OBJECTIVE

Postoperative compartment syndrome is a reported complication with known patient- and treatment-specific risk factors. Cancer patients carry unique risk factors associated with their underlying disease and long, complex procedures. While elevated serum lactate in traumatic and intensive care settings portends higher risk, no laboratory parameter has demonstrated utility in postoperative risk stratification. Postoperative extremity compartment syndrome in the study institution's cancer population was examined and whether intraoperative serum lactate correlates with postoperative compartment syndrome risk was investigated.

METHODS

A 1:2 case-control study was performed, which compared cancer patients with postoperative compartment syndrome to those who underwent similar surgical procedures without this complication. Twelve patients were matched to 24 controls by sex, age, surgical procedures, and duration of surgery. Patient and operative variables were analyzed for prognostic significance.

RESULTS

The compartment syndrome rate was 0.09% of all cases (n = 13,491); 0.12% of cases ≥ 3 h' duration (n = 9,979), and 0.25% of cases ≥ 5 h (n = 4,811). Compared with controls, the case group had higher median BMI (31.7 kg/m2 vs. 25.4 kg/m2, P = 0.001), and median intraoperative lactate level (4.05 mmol/L vs. 1.5 mmol/L, P = 0.047).

CONCLUSION

Our institutional incidence of postoperative compartment syndrome was similar to that of non-oncologic institutions. While many traditional risk factors did not prove to be influential in our patients, elevated median body mass index and intraoperative serum lactate were identified as risk factors for postoperative compartment syndrome in a cancer population.

The Value of Lactate Dehydrogenase in Predicting Rhabdomyolysis-Induced Acute Renal Failure; a Narrative Review

Introduction

Determining the diagnostic value of available biomarkers in predicting rhabdomyolysis-induced acute kidney injury (AKI) is a priority. This study aimed to review the current evidence about the value of lactate dehydrogenase (LDH) in this regard.

Methods

In this narrative review, the papers in PubMed, Embase, and web of science were studied. The keywords prognosis, prognoses, prognostic, LDH, rhabdomyolysis, emergency patients, and acute kidney failure or AKI had been selected from MeSH medical dictionary. Related papers written in English and published from November 2007 to December 2020 were selected.

Results

Finally, 14 articles were accepted for analysis. Among the selected articles, four were randomized clinical trials, seven were cross-sectional, and three were case-control studies. The results of the present review showed that abuse of illegal drugs is the most common cause of rhabdomyolysis. AKI is the most serious complication of rhabdomyolysis reported in the studies. These studies have shown a three-fold increase in AKI following drug-induced rhabdomyolysis. The review of the included articles shows that high LDH can predicts AKI, especially in critical and emergency situations such as rhabdomyolysis where there is a risk of death if diagnosed late. These studies show that LDH increases in the presence of renal failure and tissue damage.

Conclusion

Serum LDH is an appropriate and cost-effective prognostic indicator that can be used for risk classification of patients at risk for rhabdomyolysis-induced AKI.

A Preliminary Evaluation of the Kidney Function of Sugarcane Cutters From Brazil

OBJECTIVE

To evaluate clinical parameters, markers of kidney function, and skeletal muscle damage in a group of sugarcane cutters during harvesting season.

METHODS

Seventeen volunteers were assessed for anthropometrics and cardiorespiratory fitness. Blood and urine samples were collected 48-hours after the last work session. Blood was analyzed for glucose, creatine kinase, cholesterol, and a complete hemogram. Urine and blood samples were also analyzed for markers related to kidney function.

RESULTS

Volunteers were young (26 ± 6 y), had low body fat (13 ± 5%), and good cardiorespiratory fitness (41 ± 6 mL/kg/min). Classical markers of kidney function (eGFR, creatinine, cystatin C) were within the normal range. However, ten volunteers presented elevated resting serum creatine kinase (221 ± 68 U/L).

CONCLUSION

Manual sugarcane harvesting is associated with sustained skeletal muscle damage which may increase the risk for kidney injury in Brazilian sugarcane cutters.

Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis

BACKGROUND

Rhabdomyolysis is frequently occurring in critically ill patients, resulting in a high risk of acute kidney injury (AKI) and potentially permanent kidney damage due to increased myoglobin levels. The extracorporeal elimination of myoglobin might be an approach to prevent AKI, but its molecular weight of 17 kDa complicates an elimination with conventional dialysis membranes. Question of interest is, if myoglobin can be successfully eliminated with the cytokine adsorber Cytosorb® (CS) integrated in a high-flux dialysis system.

METHODS

Patients were included between 10/2014 and 05/2020 in the study population if they had an anuric renal failure with the need of renal replacement therapy, if CS therapy was longer than 90 min and if myoglobin level was > 5.000 ng/ml before treatment. The measurement times of the laboratory values were: d-1 = 24-36 h before CS, d0 = shortly before starting CS and d1 = 12-24 h after starting CS treatment. Statistical analysis were performed with Spearman's correlation coefficient, Wilcoxon test with associated samples and linear regression analysis.

RESULTS

Forty-three patients were included in the evaluation (median age: 56 years, 77% male patients, 32.6% ECMO therapy, median SAPS II: 80 points and in-hospital mortality: 67%). There was a significant equilateral correlation between creatine kinase (CK) and myoglobin at all measurement points. Furthermore, there was a significant reduction of myoglobin (p = 0.03, 95% confidence interval (CI): - 9030, - 908 ng/ml) during CS treatment, with a median relative reduction of 29%. A higher median reduction of 38% was seen in patients without ongoing rhabdomyolysis (CK decreased during CS treatment, n = 21). In contrast, myoglobin levels did not relevantly change in patients with increasing CK and therefore ongoing rhabdomyolysis (n = 22, median relative reduction 4%). Moreover, there was no significant difference in myoglobin elimination in patients with and without ECMO therapy.

CONCLUSION

Blood purification with Cytosorb® during high-flux dialysis led to a significant reduction of myoglobin in patients with severe rhabdomyolysis. The effect might be obscured by sustained rhabdomyolysis, which was seen in patients with rising CK during treatment. Prospective clinical trials would be useful in investigating its benefits in avoiding permanent kidney damage.

Etiological Spectrum and Histopathological Diagnosis of Rhabdomyolysis Associated Myoglobin Cast Nephropathy in South India

Background and Aims:

Rhabdomyolysis occurs due to injury to skeletal muscle fibers and the release of muscle constituents into the circulation. Myoglobin cast nephropathy leading to acute kidney injury is one of the most severe complications of rhabdomyolysis. This is a retrospective study which aims to analyse the clinicopathological features of myoglobin cast nephropathy.

Methods:

A total of 57 cases of myoglobin cast nephropathy were identified after performing immunohistochemical staining for myoglobin on all renal biopsies with pigment casts. The clinical, laboratory data, histopathological findings and clinical outcome of these cases were evaluated.

Results:

The mean patient age was 34.47 years (range 17-77) and the male to female ratio was 6.1:1. All patients presented with acute kidney injury with mean serum creatinine of 8.4 mg/dl (range: 1.7 to 20.8 mg/dl). Rhabdomyolysis was clinically suspected only in 31 patients. Along with myoglobin casts, acute tubular injury was present in all the biopsies. The most frequent conditions associated with myoglobin cast nephropathy in our study were snake envenomation and unaccustomed physical activities. A few activities that caused rhabdomyolysis in our patients were unique to India.

Conclusion:

Clinicians should be aware of the wide spectrum of causes for rhabdomyolysis. The classical clinical and laboratory findings of rhabdomyolysis may not be present in many of the patients. The pathologist must have a high index of suspicion, and immunohistochemical stain should be used to confirm the diagnosis.

Paracetamol use and lowered risk of acute kidney injury in patients with rhabdomyolysis

BACKGROUND

Mortality with rhabdomyolysis-associated acute kidney injury can be as high as 80%. Experimental data from mouse models of rhabdomyolysis showed that paracetamol reduces the expected increase in serum creatinine level. We aimed to assess the association between paracetamol use and the need for starting renal replacement therapy (RRT).

METHODS

We conducted a propensity score-matched cohort study in Orléans Hospital, France (a 1136-bed, public, university-affiliated and teaching hospital). All patients with serum creatine phosphokinase (CK) level > 5000 IU/L between January 1st, 2008 and December 31st, 2017 were included. A propensity score was calculated for each included patient by using multivariable logistic regression and all available baseline characteristics. The main outcome was the incidence of RRT initiation from day 1 to day 28 in the propensity score-matched cohort between patients exposed and unexposed to paracetamol.

RESULTS

Over the study period, 1065 patients with at least one CK level measurement > 5000 IU/L were included; 40 (3.8%) had at least one RRT session. Among the 343 matched pairs, 10 (2.9%) exposed and 24 (7.0%) unexposed patients underwent RRT before day 28 (P = 0.021). Primary time-to-event analysis showed that exposure to paracetamol was significantly associated with reduced absolute risk of RRT: absolute risk difference = - 3.18% (95% CI - 5.23 to - 1.20, P = 0.001). All secondary analyses showed a significantly reduced absolute risk of RRT in patients exposed to paracetamol.

CONCLUSION

Our study showed a significant association between paracetamol exposure and reduced incidence of RRT among patients with rhabdomyolysis.

Risk factors for severe acute kidney injury among patients with rhabdomyolysis

BACKGROUND

Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). The aim of the present study was to assess patients at high risk for the occurrence of severe AKI defined as stage II or III of KDIGO classification and in-hospital mortality of AKI following RM.

METHODS

We performed a retrospective study of patients with creatine kinase levels > 1000 U/L, who were admitted to the West China Hospital of Sichuan University between January 2011 and March 2019. The sociodemographic, clinical and laboratory data of these patients were obtained from an electronic medical records database, and univariate and multivariate regression analyses were subsequently conducted.

RESULTS

For the 329 patients included in our study, the incidence of AKI was 61.4% and the proportion of stage I, stage II, stage III were 18.8, 14.9 and 66.3%, respectively. The overall mortality rate was 19.8%; furthermore, patients with AKI tended to have higher mortality rates than those without AKI (24.8% vs. 11.8%; P < 0.01). The clinical conditions most frequently associated with RM were trauma (28.3%), sepsis (14.6%), bee sting (12.8%), thoracic and abdominal surgery (11.2%) and exercise (7.0%). Furthermore, patients with RM resulting from sepsis, bee sting and acute alcoholism were more susceptible to severe AKI. The risk factors for the occurrence of stage II-III AKI among RM patients included hypertension (OR = 2.702), high levels of white blood cell count (OR = 1.054), increased triglycerides (OR = 1.260), low level of high-density lipoprotein cholesterol (OR = 0.318), elevated serum phosphorus (OR = 5.727), 5000<CK ≤ 10,000 U/L (OR = 2.617) and CK>10,000 U/L (OR = 8.093). Age ≥ 60 years (OR = 2.946), sepsis (OR = 3.206) and elevated prothrombin time (OR = 1.079) were independent risk factors for in-hospital mortality in RM patients with AKI.

CONCLUSIONS

AKI is independently associated with mortality in patients with RM, and several risk factors were found to be associated with the occurrence of severe AKI and in-hospital mortality. These findings suggest that, to improve the quality of medical care, the early prevention of AKI should focus on high-risk patients and more effective management.

The Association Between Rhabdomyolysis, Acute Kidney Injury, Renal Replacement Therapy, and Mortality

BACKGROUND

We examined the association between creatine phosphokinase level in rhabdomyolysis patients and risk of acute kidney injury, renal replacement therapy, and death within 30 days.

METHODS

The cohort included patients admitted with rhabdomyolysis from November 1, 2011 to March 1, 2014. Rhabdomyolysis was defined as a creatine phosphokinase level higher than 1000 U/L. Information on laboratory variables was obtained from a laboratory database. Medical data were obtained from registries. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcome (KDIGO) guidelines. The 30-day risk of outcomes was estimated using the cumulative incidence method. Spline regression applied to imputed datasets with adjustment for baseline variables was used to assess the appropriateness of the categorization chosen for creatine phosphokinase (1000-5000 U/L, 5001-15,000 U/L, and 15,000+ U/L).

RESULTS

The study included 1027 patients (58.2% male) with a median age of 73.5 years. The median creatine phosphokinase level at rhabdomyolysis diagnosis was 2257 U/L (interquartile range=1404-3961 U/L). The 30-day risks of acute kidney injury according to the three creatinine phosphokinase levels were 42% (95% CI=38-45%), 44% (95% CI=36-52%), and 74% (95% CI=57-85%), respectively, and the risks of renal replacement therapy for the three levels were 3% (95% CI=2-5%), 4% (95% CI=2-7%), and 11% (3-23%), respectively. The 30-day risk of death was 17% (95% CI=14-20%), 16% (95% CI=11-22%), and 11% (95% CI=3-23%), respectively. With increasing creatine phosphokinase levels, the spline plots supported the increasing risk of acute kidney injury and renal replacement therapy, as well as a decreasing risk of death. However, the risk estimates for renal replacement therapy and death were imprecise.

CONCLUSION

Elevated initial creatine phosphokinase values were associated with an increased risk of acute kidney injury, while estimates of the risk of renal replacement therapy and death were imprecise.

The Utility of Serum Creatinine Kinase in Emergency Department Patients with Possible Substance-use Related Conditions

INTRODUCTION

Our goal was to assess the diagnostic utility and temporal kinetics of serum creatine kinase (CK) measurement as a predictor of acute kidney injury (AKI) in emergency department (ED) patients who present with possible substance-use related conditions.

METHODS

This was a retrospective chart review of ED patients with a urine drug screen (UDS) ordered and resulted between 2009-2013. Data was extracted electronically from EPIC Systems electronic health records, populated into a Microsoft Excel file, and includes demographics, chief complaint, vital signs, neuro-psychiatric physical examination findings, laboratory findings, psychiatric consult order time, ED medications given, orders, disposition and its time, and diagnosis.

RESULTS

Of 74,970 patients with an ED UDS, 22,101 (29%) had at least one CK measured. After inclusion and exclusion criteria, 2858 (13%) remained. Mean (standard deviation [SD]) age was 43.3 (12.5) years, 73% were male, 61% Black, 22% White, and 17% Hispanic. Mean (SD) ED length of stay was 10.4 (5.8) hours, and 56.7% were hospitalized. On average, CK was higher at 6-12 hours (p<0.001) and 12-18 hours (p=0.016) compared to 6 hours. CK was lower at 42-56 hours (p = 0.011), 72 hours (p<0.001), and over 72 hours (p<0.001), compared to 6 hours. Maximum CK was determined in those with >2 CK measures. We defined AKI risk as a creatinine of >1.4 milligrams per deciliter based on RIFLE criteria. AKI risk was calculated among those with at least two creatinine values in 522 patients. We identified five (1%) patients as having AKI risk. The odds of AKI risk were not associated with increase in CK over time.

CONCLUSION

In 74,970 ED patients undergoing UDS testing for potential substance abuse, there was no identifiable CK level associated with AKI risk. In patients with possible substance-use conditions, CK continued to trend up even after six hours from door time and began to decrease after 42 hours. We found no value in repeated ED CK measures. Disposition should not be based solely on CK levels.

Biomarkers, Creatine Kinase, and Kidney Function of Special Operation Candidates During Intense Physiological Training

INTRODUCTION

The purpose of this pilot study was to assess for biomarkers indicative of passing intense physical training and establishing normative values within the tactical athlete population. Unfortunately, none of the biomarkers assessed were indicative of passing training, however, glucose, blood urea nitrogen, and creatine kinase (CK) levels stood out as abnormal. CK levels are commonly used in conjunction with muscle pain and/or myoglobinurea to diagnose exertional rhabdomyolysis (ER) in athletes and the military population. However, research shows that high CK levels may not correlate with acute kidney failure in ER.

MATERIALS AND METHODS

After IRB approval and informed consent, blood samples were obtained from 21 volunteers during two phases of the combat control training pipeline: the first phase (12 participants) was 2 hours of daily physical training followed by 8 hours of academics, and the second phase (nine volunteers) a grueling, 72 hour, intense training cycle (stress inoculation training, SIT) with a historic pass rate of only 50%. Biomarkers were also tracked 48 hours after cessation of SIT.

RESULTS

None of the biomarkers assessed showed a correlation with passing SIT, but high CK levels were well above the diagnostic threshold for ER-as high as 28,000 u/L. At a single point in time, a significant correlation did not exist between CK and others markers associated with rhabdomyolysis. Across time, partial correlations controlling for subject did exist between CK and other markers.

CONCLUSIONS

In our low-powered case control study (pilot study), a nonpathologic elevation of CK is prevalent in high-intensity military training, but not shown to correlate with values associated with acute kidney injury. We assume that real-time collection of these markers could be used once sensors are capable of real-time collection and have the potential for diagnostic affordance. When measured in a between subjects design, our study showed a lack of significance when correlating markers of acute renal injury and elevation of CK. However, when utilized for tracking purposes (within subjects design), the results do show a positive correlation between CK and renal failure biomarkers-specifically only at high physiological stress points.

A patient with severe rhabdomyolysis and high levels of creatinine kinase had renal functions fully recovered after haemodialysis: a case report

Rhabdomyolysis is diagnosed based on the levels of blood biomarkers such as creatine kinase (CK), but the use of CK levels to predict long-term renal function remains controversial. This current report presents a case with a very high CK level with the presentation of acute kidney injury (AKI) who regained full renal function. A 29-year-old man, in a manic mood and presenting with dyspnoea, was admitted to hospital following an episode of ketamine use along with a history of drug abuse. The laboratory analyses identified rhabdomyolysis (CK, 35 266 U/l) and AKI (serum creatinine, 3.96 mg/dl). Despite treatment with intravenous normal saline (4000 ml/day), his CK level reached at least 300 000 U/l. He underwent 13 sessions of haemodialysis and his renal function fully recovered. The final measurements were serum creatinine 1.0 mg/dl and CK 212 U/l. These findings support the view that the predictive power of CK level on AKI is limited, especially regarding long-term renal function. Close follow-up examinations of renal function after haemodialysis are mandatory for patients with rhabdomyolysis.

Rhabdomyolysis: a case-based critical reflection on its causes and diagnosis

Rhabdomyolysis is a rare and complex condition that involves injury of the skeletal muscle fibres, resulting in the release of substances such as creatine kinase and myoglobin. It is associated with acute kidney injury and mortality. This article describes the case of a 40-year-old man who presented to the emergency department after an overdose of tramadol hydrochloride. It uses critical reflection to explore traumatic and non-traumatic causes of rhabdomyolysis and reviews the literature relating to the diagnosis of rhabdomyolysis through laboratory and point-of-care testing. To ensure the timely identification of patients at risk of deterioration, emergency nurses need to be aware of the potential causes and the clinical signs and symptoms of rhabdomyolysis.

Immunomodulatory role of recombinant human erythropoietin in acute kidney injury induced by crush syndrome via inhibition of the TLR4/NF-κB signaling pathway in macrophages

Objective: The present study aimed to investigate whether recombinant human erythropoietin (rHuEPO) plays an immunomodulatory function by regulating the TLR4/NF-κB signaling pathway.Materials and methods: C57BL/6 mice were intraperitoneally injected with rHuEPO and, half an hour later, with 50% glycerol at the dose of 7.5 ml/kg to induce crush syndrome (CS)-acute kidney injury (AKI). The levels of TNF-α, IL-1β, IL-6, serum creatinine (Scr), and creatine kinase (CK) were measured. The kidney tissues were analyzed by HE staining, and macrophage infiltration was detected by immunohistochemistry. Double immunofluorescence staining, RT-qPCR, and western blotting were conducted to analyze TLR4/NF-κB p65 expression. Ferrous myoglobin was co-cultured with RAW264.7 cells to mimic crush injury and the production of proinflammatory cytokines. The expression levels of TLR4 and NF-κB p65 were measured.Results: In vivo study results revealed that rHuEPO ameliorated renal function, tissue damage, production of proinflammatory cytokines, and macrophage infiltration in the kidneys. The protein and mRNA expression levels of genes involved in the TLR4/NF-κB signaling pathway in CS-induced AKI mice were upregulated (p < .05). Meanwhile, the expression levels of TLR4, NF-κB p65, and proinflammatory cytokines in RAW264.7 cells were downregulated in CS-AKI mice injected with rHuEPO (p < .05).Conclusions: Our results demonstrated the immunomodulatory capacity of rHuEPO and confirmed that rHuEPO exerts protective effects against CS-induced AKI by regulating the TLR4/NF-κB signaling pathway in macrophages. Therefore, our findings highlight the therapeutic potential of rHuEPO in improving the prognosis of CS-AKI patients.

Carbon Monoxide Rescues the Developmental Lethality of Experimental Rat Models of Rhabdomyolysis-Induced Acute Kidney Injury

Many victims, after being extricated from a collapsed building as the result of a disaster, suffer from disaster nephrology, a term that is referred to as the crush syndrome (CS). Recommended treatments, which include dialysis or the continuous administration of massive amounts of fluid are not usually easy in cases of such mass natural disasters. In the present study, we examined the therapeutic performance of a biomimetic carbon monoxide (CO) delivery system, CO-enriched red blood cells (CO-RBCs), on experimental animal models of an acute kidney injury (AKI) induced by traumatic and nontraumatic rhabdomyolysis, including CS and rhabdomyolysis with massive hemorrhage shock. A single CO-RBC treatment was found to effectively suppress the pathogenesis of AKI with the mortality in these model rats being improved. In addition, in further studies using glycerol-induced rhabdomyolysis model rats, the pathogenesis of which is similar to that for the CS, AKI and mortality were also reduced as the result of a CO-RBC treatment. Furthermore, CO-RBCs were found to have renoprotective effects via the suppression of subsequent heme protein-associated renal oxidative injury; the oxidation of myoglobin in the kidneys, the generation of reactive oxygen species by free heme produced from degraded-cytochrome P450 and hemoglobin-associated renal injury. Because CO-RBCs can be prepared and used at both hospitals and at a disaster site, these findings suggest that CO-RBCs have the potential for use as a novel cell therapy against both nontraumatic and traumatic rhabdomyolysis including CS-induced AKI. SIGNIFICANCE STATEMENT: After mass natural and man-made disasters, people who are trapped in collapsed buildings are in danger of acute kidney injury (AKI), including crush syndrome (CS)-related AKI. This paper reports that carbon monoxide-enriched red blood cells (CO-RBCs), which can be prepared at both hospitals and disaster sites, dramatically suppressed the pathogenesis of CS-related AKI, thus improving mortality via suppressing heme protein-associated renal injuries. CO-RBCs have the potential for serving as a practical therapeutic agent against disaster nephrology associated with the CS.

Posterior Tibial Nerve Stimulation in Fecal Incontinence: A Systematic Review and Meta-Analysis

Introduction:

The present systematic review and meta-analysis aims to investigate the role of Posterior Tibial Nerve Stimulation (PTNS) in the control of Fecal Incontinence (FI).

Methods:

Two independent reviewers extensively searched in the electronic databases of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, and Scopus for the studies published until the end of 2016. Only randomized clinical trials were included. The studied outcomes included FI episodes, FI score, resting pressure, squeezing pressure, and maximum tolerable pressure. The data were reported as Standardized Mean Differences (SMD) with 95% confidence interval.

Results:

Five articles were included in the present study (249 patients under treatment with PTNS and 239 in the sham group). Analyses showed that PTNS led to a significant decrease in the number of FI episodes (SMD=−0.38; 95% CI: −0.67–0.10; P=0.009). Yet, it did not have an effect on FI score (SMD=0.13; 95% CI: −0.49–0.75; P=0.68), resting pressure (SMD=0.12; 95% CI: −0.14–0.37; P=0.67), squeezing pressure (SMD=−0.27; 95% CI: −1.03–0.50; P=0.50), and maximum tolerable pressure (SMD=−0.10; 95% CI: −0.40–0.24; P=0.52).

Conclusion:

Based on the results, it seems that the prescription of PTNS alone cannot significantly improve FI.

Rhabdomyolysis-induced acute kidney injury in a patient with undifferentiated connective tissue disease: A case report and literature review rhabdomyolysis-induced AKI in a patient with UCTD

RATIONALE

Acute kidney injury (AKI) accounts for 8% to 16% of hospital admissions and can quadruple hospital mortality, placing a serious burden on the health economy. Acute kidney injury (AKI) is mainly caused by dehydration, shock, infection, sepsis, heart disease, or as a side-effect of nephrotoxic drugs. About 10% to 60% of patients with rhabdomyolysis develop AKI, and 10% of AKI is attributable to rhabdomyolysis. However, rhabdomyolysis-induced AKI secondary to undifferentiated connective tissue disease (UCTD) has rarely been reported before.

PATIENT CONCERNS

We report the case of a 50-year-old male of UCTD presented with dark brown urine, swelling and edema of the upper limbs, and decreased urine output.

DIAGNOSIS

The patient was diagnosed with rhabdomyolysis-induced AKI secondary to UCTD.

INTERVENTIONS

The patient was successfully treated with intravenous methylprednisolone with other supportive treatment.

OUTCOMES

After 3 days of initiating treatment of medicinal charcoal tablets, sodium bicarbonate and intravenous fluids upon admission, the patient's serum creatinine changed mildly from 145.0 μmol/L to 156.0 μmol/L, but the urinary output increased from 1000 mL/24 h to 2400 mL/24 h, with his creatine kinase (CK) and myoglobin rose from 474 IU/L to 962 IU/L and from 641.5ng/mL to 1599 ng/mL, respectively. We then tried to empirically initiate UCTD therapy by giving corticosteroids. After the administration of the 40 mg of methylprednisolone daily, the serum creatinine level dropped to 97 μmol/L the second day, CK decreased to 85 IU/L within 1 week and myoglobin decreased to 65.05 ng/mL within 10 days. When maintenance dose of 4 mg daily was given, the patient showed no abnormalities in creatinine or CK levels.

LESSONS

There have been few reports on the association between rhabdomyolysis-induced AKI and UCTD and its mechanism remains unclear. Clinicians should be aware of UCTD as a possible cause to rhabdomyolysis-induced AKI.

Exertional rhabdomyolysis in a 21-year-old healthy man resulting from lower extremity training: A case report

RATIONALE

The incidence exercise-induced rhabdomyolysis is increasing in the healthy general population. Rhabdomyolysis can lead to the life-threatening systemic complications of acute kidney injury (AKI), compartment syndrome, and disseminated intravascular coagulopathy.

PATIENT CONCERNS

A 21-year-old man had bilateral lower limb pain and soreness, dark brown urine after lower exremity training. Laboratory results showed that creatinine kinase (CK) and myoglobin (Mb) increased to 140,500 IU/L and 8632 μg/L respectively, with elevated liver enzymes, Scr, and proteinuria.

DIAGNOSES

Exercise-induced rhabdomyolysis with AKI.

INTERVENTIONS

The patient was hospitalized and treated with vigorous hydration and sodium bicarbonate for 6 days.

OUTCOMES

After 6 days of treatment, the patient had a significant decrease in the CK and Mb levels. His renal function returned to normal. His laboratory tests had completely normalized during 2-week follow-up.

LESSONS

Exercise-induced rhabdomyolysis can cause serious complications such as AKI. Delayed diagnosis can be critical, so timely manner should be taken to achieve a favorable prognosis.

Prevention of rhabdomyolysis-induced acute kidney injury - A DASAIM/DSIT clinical practice guideline

BACKGROUND

Rhabdomyolysis-induced acute kidney injury (AKI) is a common and serious condition. We aimed to summarise the available evidence on this topic and provide recommendations according to current standards for trustworthy guidelines.

METHODS

This guideline was developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The following preventive interventions were assessed: (a) fluids, (b) diuretics, (c) alkalinisation, (d) antioxidants, and (e) renal replacement therapy. Exclusively patient-important outcomes were assessed.

RESULTS

We suggest using early rather than late fluid resuscitation (weak recommendation, very low quality of evidence). We suggest using crystalloids rather than colloids (weak recommendation, low quality of evidence). We suggest against routine use of loop diuretics as compared to none (weak recommendation, very low quality of evidence). We suggest against use of mannitol as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of any diuretic as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of alkalinisation with sodium bicarbonate as compared to none (weak recommendation, low quality of evidence). We suggest against the routine use of any alkalinisation as compared to none (weak recommendation, low quality of evidence). We suggest against routine use of renal replacement therapy as compared to none (weak recommendation, low quality of evidence). For the remaining PICO questions, no recommendations were issued.

CONCLUSION

The quantity and quality of evidence supporting preventive interventions for rhabdomyolysis-induced AKI is low/very low. We were able to issue eight weak recommendations and no strong recommendations.

Rhabdomyolysis: Patterns, Circumstances, and Outcomes of Patients Presenting to the Emergency Department

Background

Exertional rhabdomyolysis is a condition resulting from skeletal muscle damage and release of intracellular toxins into the systemic circulation as a consequence of extreme physical effort. With increasing numbers of people partaking in high-intensity workouts, we hypothesized that the rate of presentation of exertional rhabdomyolysis was also increasing.

Methods

All presentations to the Princess Alexandra Hospital emergency department in Brisbane, Australia between March 2005 and December 2016 were identified from the electronic medical record. Records of patients with a serum creatine kinase value >1,000 U/L or a urinary myoglobin >5 mg/L were extracted for determination of whether the rhabdomyolysis was attributable to physical exertion.

Results

From a total of 1,957 rhabdomyolysis cases, 89 patients (70.8% male) were identified as having exertional rhabdomyolysis. The frequency of presentation increased from 0.28/10,000 presentations in 2005 to 3.5/10,000 in 2015. Gym-induced exertional rhabdomyolysis was the primary subcategory (53.9%) for these cases, and manual labor was the second most common subcategory (15.7%).

Conclusion

This study provides evidence for increasing instances of exertional rhabdomyolysis in the Brisbane, Australia metropolitan area and adds to the current knowledge about those who develop exertional rhabdomyolysis. Future studies are warranted to investigate if similar trends are being seen in other regions and to identify the circumstances leading to the presentation. Such knowledge would be valuable for devising strategies to prevent and mitigate injury.

Awareness of acute kidney injury risk factors and perspectives on its practice guidelines

OBJECTIVES

Identifying and assessing risk factors for acute kidney injury (AKI) are crucial for its early detection and possible intervention to prevent AKI and associated adverse outcomes. This study aimed to investigate AKI risk factor awareness and risk assessment by healthcare professionals and to evaluate perspectives on the Kidney Disease Improving Global Outcomes AKI guidelines.

METHODS

This cross-sectional survey-based study was conducted among healthcare professionals (physicians and pharmacists) at XXX from December 2016 to February 2017.

RESULTS

Among the respondents (117 physicians and 135 pharmacists), 78% were aged ≤38 years, 57% were men, and 70% had <9 years of experience. Respondents varied in their knowledge of the 25 risk factors for AKI and 15 nephrotoxic drugs: 96% were aware of nephrotoxic medication, whereas 20% acknowledged female sex as an AKI risk factor, and 92% agreed with aminoglycoside, while 47% agreed with ciprofloxacin as nephrotoxic drugs. A significantly higher percentage of physicians identified individual AKI risk factors than pharmacists; however, a significantly higher percentage of pharmacists identified individual AKI-causing drugs than physicians. Although 77% of respondents encountered AKI cases in their practice, only half of them performed AKI risk assessment, and 42% stratified patients' AKI risk according to their presenting risk factors or documented AKI in previous medical history. Seventy-one percent of respondents agreed that practice guidelines improve patient outcome, and 69% thought these guidelines help standardize care and ensure that patients are treated in consistently.

CONCLUSION

While the majority of the respondents had a positive perspective toward AKI guidelines, a large variation in their knowledge of AKI risk factors, risk assessment, and nephrotoxic drugs was found. Educational efforts are needed to raise awareness and thereby reduce this variation.

Electrical injury - a dual center analysis of patient characteristics, therapeutic specifics and outcome predictors

BACKGROUND

Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce.

METHODS

Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998-2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes.

RESULTS

Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06-1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27-0.834, p = 0.010) and limb amputations (OR 14.26, 95% CI 1.26-162.1, p = 0.032).

CONCLUSIONS

Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary.