Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis

After the Türkiye Earthquake: The Experience of a Pediatric Emergency Department in a University Hospital Distant from the Disaster Area

INTRODUCTION

Earthquakes rank among the most deadly natural disasters, and children are particularly affected due to their inherent vulnerability. Following an earthquake, there is a substantial increase in visits to emergency services. These visits stem not only from patients seeking care for physical traumas resulting from the earthquake and its subsequent complications, but also from individuals affected by the circumstances created by the disaster.

STUDY OBJECTIVE

This study aims to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after the earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area.

METHODS

The medical records of children who presented to the PED from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Children rescued from under rubble were categorized as Group 1, those affected by earthquake conditions as Group 2, and patients seeking medical attention due to the follow-up of chronic illnesses were considered as Group 3. Patient data, including sociodemographic characteristics, time period under rubble (TPR), laboratory findings, and details of medical and surgical procedures, developing acute kidney injury (AKI), and the requirement for hemodialysis were recorded.

RESULTS

A total of 252 children were enrolled in the study, with 52 (20.6%) in Group 1, 180 (71.4%) in Group 2, and 16 (6.0%) in Group 3. The median age was six (IQR = 1.7-12.1) years. In the first group (n = 52), 46 (85.2%) children experienced crush injuries, 25 children (46.3%) developed crush syndrome, and 14 of them (14/25; 56.0%) required dialysis. In the second group, the most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%). For children in the third group, pediatric neurology (n = 5; 33.3%), pediatric oncology (n = 4; 25.0%), and pediatric nephrology (n = 3; 18.8%) were the most frequently referred specialties.

CONCLUSION

Crush injuries, crush syndrome, and AKI were the most common problems in the early days following the earthquake. Along with these patients, children who were affected by the environmental conditions caused by the earthquake, as well as children with chronic illnesses, also accounted for a significant portion of visits to the PED, even if they were distant from the disaster area.

Factors predicting kidney replacement therapy in pediatric earthquake victims with crush syndrome in the first week following rescue

Crush syndrome due to traumatic rhabdomyolysis is one of the most significant problems to occur following earthquakes. On February 6, 2023, millions of people in Turkey were affected by two consecutive Kahramanmaraş earthquakes. The present study reports the analysis of clinical and laboratory findings of crush syndrome in pediatric earthquake victims admitted to our hospital from our region where the earthquake had a devastating effect. Clinical and laboratory findings concerning earthquake victims with crush syndrome were analyzed within the first week to determine what factors are predictive of kidney replacement therapy (KRT). The data of patients were retrospectively collected from medical records. A total of 310 children were admitted as earthquake victims to the pediatric emergency department. Ninety-seven (31%) of these patients had crush syndrome. Fifty-three (55%) of those with crush syndrome were female. The mean age was 10.9 ± 4.7 years, and the mean time under the rubble was 30.6 ± 23.8 h. Twenty-two patients (23%) required KRT. Hemodialysis was applied to 16 (73%) of them, and hemodiafiltration was applied to the other six (27%) in the pediatric intensive care unit. Regarding creatine kinase (CK) levels, the area under the receiver operating characteristic (ROC) curve (AUC) for predicting KRT was 0.905 (95% confidence interval [CI] 0.848-0.963; p < 0.001). The optimal cut-off value was 40,000 U/L with a sensitivity of 86% and a specificity of 83%. In terms of the percentage of body area crushed, the AUC for predicting KRT was 0.907 (95% CI 0.838-0.976; p < 0.001). The optimal cut-off value was 30% with a sensitivity of 86% and a specificity of 88%. Multiple logistic regression analysis showed that each 10% increase in body area crushed (OR 4.16, 95% CI 1.58-10.93, p = 0.004) and 1 mg/dl increase in the serum phosphorus level (OR 4.19, 95% CI 1.71-10.28, p = 0.002) were significant risk factors for dialysis treatment.

CONCLUSIONS

Crush syndrome and kidney problems are common following disasters like earthquakes. Clinical and laboratory findings at admission can predict dialysis requirement in earthquake victims. While CK elevation, body area crushed percentage, and increased phosphorus level were predictive of dialysis treatment, time under the rubble was not. Even if the patients were under the rubble for a short time, acute kidney injury (AKI) may develop as a result of severe hypovolemia due to crush injuries, and patients may need KRT.

WHAT IS KNOWN

•Crush syndrome after earthquakes needs to be treated carefully in victims and can cause AKI and mortality when not treated timely and appropriately.

WHAT IS NEW

•CK level elevation, body area crushed percentage, and increased phosphorus level are predictive of dialysis treatment. •The time under the rubble may not be predictive of dialysis requirement.

Demographic and Clinical Characteristics of Earthquake Victims Presented to the Emergency Department with and without Crush Injury upon the 2023 Kahramanmaraş (Turkey) Earthquake

INTRODUCTION

Earthquakes are sudden-onset natural disasters that are associated with substantial material damage, resulting in the collapse of built environment with a high rate of mortality, injury, and disability. Crush syndrome, which can be seen after devastating earthquakes, can lead to acute kidney injury (AKI) and patients may require amputation, fasciotomy, and dialysis. Supportive treatment has an important role in the prognosis of these patients.

STUDY OBJECTIVE

The aim of this study was to investigate the demographic and clinical characteristics of traumatic earthquake survivors admitted to the emergency department (ED) of a hospital, which was close to the earthquake zone but not affected by the earthquake, after the February 6, 2023 Kahramanmaraş (Turkey) earthquakes.

MATERIALS AND METHODS

This study was conducted by retrospectively analyzing the data of 1,110 traumatized earthquake survivors admitted to the ED of a tertiary care university hospital from February 6th through February 20th, 2023. Age; gender; time of presentation; presence of comorbid diseases; ED triage category; duration of stay under debris; presence of additional trauma; laboratory tests; presence of AKI; presence of crush injury and injury sites; supportive treatment (fluid replacement and intravenous [IV] sodium bicarbonate); need for amputation, dialysis, and fasciotomy; duration of hospitalization; and outcome of ED were evaluated.

RESULTS

Of the 1,110 traumatic victims in this study, 55.5% were female patients. The mean age of the patients was 45.94 (SD = 16.7) years; the youngest was 18 years old and the oldest was 95 years old. Crush injury was detected in 18.8% and AKI in 3.0% of the patients. Dialysis, amputation, and fasciotomy were required in 1.6%, 2.8%, and 1.4% of the patients, respectively. In total, 29.2% of patients were hospitalized, including 2.9% admitted to the intensive care unit (ICU) and 26.3% to the relevant ward. In total, 0.3% of the patients included in the study died at ED.

CONCLUSION

Post-earthquake patients may present with crush injury, AKI may develop, and fasciotomy, amputation, and dialysis may be needed, so hospitals and EDs should be prepared for natural disasters such as earthquakes.

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Crush injury and syndrome: A review for emergency clinicians

INTRODUCTION

Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome.

OBJECTIVE

This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians.

DISCUSSION

Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury).

CONCLUSIONS

Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

Molecular Mechanisms of Rhabdomyolysis-Induced Kidney Injury: From Bench to Bedside

Rhabdomyolysis-induced acute kidney injury (RIAKI) occurs following damage to the muscular sarcolemma sheath, resulting in the leakage of myoglobin and other metabolites that cause kidney damage. Currently, the sole recommended clinical treatment for RIAKI is aggressive fluid resuscitation, but other potential therapies, including pretreatments for those at risk for developing RIAKI, are under investigation. This review outlines the mechanisms and clinical significance of RIAKI, investigational treatments and their specific targets, and the status of ongoing research trials.

Dexmethylphenidate-Induced Rhabdomyolysis by Interaction With Aromatase Inhibitor

Rhabdomyolysis secondary to prescription drug-drug interactions can be an overlooked life-threatening emergency. Amphetamines and similar substances have been associated with muscle lysis secondary to increased sympathetic activity that can cause myotoxicity, hyperthermia, and increased muscular activity. Anabolic steroids may also be a predisposing factor in developing rhabdomyolysis. A high index of suspicion for drug-induced rhabdomyolysis in a patient presenting with atraumatic extremity pain can facilitate rapid diagnosis and treatment. We present a case of drug-induced rhabdomyolysis likely secondary to a previously unreported medication interaction.

The Anesthetic Techniques for Earthquake Victims in Indonesia

Introduction

In Lombok, three-large magnitude earthquakes occurred in July 2018 and caused major losses: 564 victims died, 1684 were injured, 445,343 people became refugees, and 215,628 houses were damaged. It damaged 408 health facilities, consisting of 89 public health centers, 13 hospitals, 174 auxiliary public health centers, 132 village health posts.

Aim

The purpose of this study is to describe the anesthetic techniques that were used to treat earthquake victims.

Methods

This study was a descriptive cross-sectional study that was conducted by collecting total sampling from all earthquake victims treated in the emergency room (ER) of the regional public hospital (RSUD NTB) on August 6th and 7th, 2018, and all victims who underwent surgery during August 5th–25th, 2018. The data that were collected were surgery type, anesthetic techniques, and anesthesia drugs that were used.

Results

The results show that the highest number of patients were treated in the ER during the first seven days after the earthquake and that this number then decreased over several weeks. The majority of patients treated were trauma patients who needed orthopedic surgery. General anesthesia was more widely used than regional anesthesia, but the difference was not significant. The most commonly used regional anesthetic was lidocaine hyperbaric 75–100 mg and clonidine 30–50 mcg combination. Regional anesthesia techniques have better results in cases of lower limb injury, but it is difficult to be applied in earthquake victims who present with complex injuries and limited resources.

The peroxidatic activities of Myoglobin and Hemoglobin, their pathological consequences and possible medical interventions

Under those pathological conditions in which Myoglobin and Hemoglobin escape their cellular environments and are thus separated from cellular reductive/protective systems, the inherent peroxidase activities of these proteins can be expressed. This activity leads to the formation of the highly oxidizing oxo-ferryl species. Evidence that this happens in vivo is provided by the formation of a covalent bond between the heme group and the protein and this acts as an unambiguous biomarker for the presence of the oxo ferryl form. The peroxidatic activity also leads to the oxidation of lipids, the products of which can be powerful vasoconstrictive agents (e.g. isoprostanes, neuroprostanes). Here we review the evidence that lipid oxidation occurs following rhabdomyolysis and sub-arachnoid hemorrhage and that the products formed from arachidonic acid chains of phospholipids lead, through vasoconstriction, to kidney failure and brain vasospasm. Intervention in these pathological conditions through administration of reducing agents to remove ferryl heme is discussed. Through-protein electron transfer pathways that facilitate ferryl reduction at low reductant concentration have been identified. We conclude with consideration of the therapeutic use of Hemoglobin Based Oxygen carriers and how the toxicity of these may be reduced by engineering such electron transfer pathways into hemoglobin.

Kidney problems in disaster situations

Mass disasters, particularly earthquakes, cause many medical problems, including kidney problems, but an organized approach to cope with them was initiated only at the end of previous century, subsequent to the Armenian Spitak earthquake in 1988. Originally, interventions were focused on acute kidney injury (AKI) following crush injury and rhabdomyolysis in victims who had been trapped under the debris of collapsed buildings. However, similar problems were also registered in the context of other catastrophic events, especially man-made disasters like wars and torture. Other kidney-related problems, such as the preservation of treatment continuity in chronic kidney disease (CKD), especially in maintenance dialysis patients, deserved attention as well. Specific therapeutic principles apply to disaster-related kidney problems and these may differ from usual day-to-day clinical practice. Those approaches have been formulated in global and specific country-related guidelines and recommendations. It is clear that a well-conceived and organized management of kidney diseases in disasters benefits outcomes. Furthermore, it may be useful if the model and philosophy that were applied over the last three decades could be adapted by broadening the scope of disasters leading to intervention. Actions should be guided and coordinated by a panel of experts steering ad hoc interventions, rather than applying the "old" static model where a single coordinating center instructs and uses volunteers listed long before a potential event occurs.

Case Report: Prevention of Rhabdomyolysis-Associated Acute Kidney Injury by Extracorporeal Blood Purification With Cytosorb®

Acute kidney injury (AKI) is a severe complication of rhabdomyolysis. The pathophysiology of rhabdomyolysis-associated AKI is complex, but myoglobin related damage plays a major role. Extracorporeal removal of myoglobin is therefore an appealing target to prevent AKI, however, attempts to remove myoglobin with standard dialysis membranes have so far been disappointing. Here we report the case of a 12-year-old boy with severe trauma-related rhabdomyolysis where we successfully utilized continuous renal replacement therapy in combination with Cytosorb^® to eliminate myoglobin and prevent AKI. The early use of extracorporeal myoglobin removal with Cytosorb^® after severe rhabdomyolysis might be an option and should be further investigated as a tool to prevent the development of AKI.

Diagnosis and Management of Rhabdomyolysis in the Absence of Creatine Phosphokinase: A Medical Record Review

INTRODUCTION

Rhabdomyolysis is often encountered in austere environments where the diagnosis can be challenging due to the expense or unavailability of creatine phosphokinase (CPK) testing. CPK concentration ≥5,000 U/L has previously been found to be a sensitive marker for progression to renal failure. This study sought to propose a model utilizing an alternate biomarker to allow for the diagnosis and monitoring of clinically significant rhabdomyolysis in the absence of CPK.

MATERIALS AND METHODS

We performed a retrospective chart review of 77 patients admitted to a tertiary medical center with a primary diagnosis of rhabdomyolysis. A linear regression model with aspartate aminotransferase (AST) as the independent variable was developed and used to predict CPK ≥5,000 U/L on admission and CPK values on subsequent hospital days. The study was approved and monitored by the Institutional Review Board at Walter Reed National Military Medical Center.

RESULTS

Ln(AST) explained over 80% of the variance in ln(CPK) (adjusted R2 = 0.802). The diagnostic accuracy to predict CPK ≥5,000 U/L was high (AUC 0.959; 95% CI: 0.921-0.997, P < 0.001). A cut point of AST ≥110 U/L in our study population had a 97.1% sensitivity and an 85.7% specificity for the detection of a CPK value ≥5,000 U/L. The agreement between actual CPK and predicted CPK for subsequent days of hospitalization was fair with an intraclass correlation coefficient of 0.52 (95% CI: 0.38-0.63). The developed model based on day 1 data tended to overpredict CPK values on subsequent hospital days.

CONCLUSIONS

We propose a threshold concentration of AST that has an excellent sensitivity for detecting CPK concentration ≥5,000 U/L on day of admission in a patient population with a diagnosis of rhabdomyolysis. A formula with a fair ability to predict CPK levels based on AST concentrations on subsequent hospital days was also developed.

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.

Nerve Lesions in Volkmann Ischemic Contracture

Volkmann ischemic contracture (VIC) is a late sequela of acute compartment syndrome and consists of extensive muscle necrosis, fibrosis, contracture, and variable degrees of neural dysfunction. The outcome depends on successful restoration of muscle and neural function. The timing of surgery is often determined by the development of contractures and is delayed in the interest of observing some spontaneous recovery and infarct maturation. This period of observation may be detrimental to nerve function with gradual formation of scar tissue and worsening constrictive neuropathy. Early intervention appears to be more effective in preventing further nerve damage and restoring protective sensation. In this article, common features of compartment syndrome, frequently seen nerve lesions, and the effect of timing of surgical intervention on the outcome of VIC were reviewed in the light of the current basic and clinical science literature.

A Case of Docetaxel-Induced Rhabdomyolysis

Docetaxel is an antimicrotubule agent with activity in a variety of cancers. Its toxicity profile includes myelosuppression, fluid retention/edema, and peripheral neuropathy. It is also associated with myalgias but the frequency and extent of this toxicity are not well described. Here, we present a case of a 48-year-old female with breast cancer who developed bilateral proximal leg pain and inability to walk two weeks after the third cycle of docetaxel and cyclophosphamide. Initial workup showed elevated creatinine kinase (CK) levels which trended up to 9000 U/L suggesting rhabdomyolysis. She was treated with IV isotonic fluids without renal complications. Her CK was 1800 U/L at discharge and normalized two weeks post-discharge. To our knowledge, this is one of the few reports of docetaxel-induced rhabdomyolysis. The purpose of this report is to alert physicians of this rare but morbid complication.

Renal Crisis in Children during Armed Conflict

Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.

Illicit drug use and acute kidney injury in patients admitted to hospital with rhabdomyolysis

BACKGROUND

Severe rhabdomyolysis is associated with acute kidney injury, but it is unclear if patients developing rhabdomyolysis after illicit drug use have a higher risk of acute kidney injury compared to other causes.

AIMS

To provide a descriptive analysis of patients admitted with rhabdomyolysis, with a focus on illicit drug use, and to determine if illicit drug use was an independent predictor for acute kidney injury or renal replacement therapy.

METHODS

We conducted a 5-year cohort study of patients admitted to Monash Health, a tertiary referral hospital network. We identified adult patients with muscle injury from ICD-10 AM codes, serum creatine kinase level greater than 1000 U/mL, and a clinical history consistent with rhabdomyolysis. We determined the prevalence and type of illicit drug involved and determined the association between illicit drug use and renal outcomes by logistic regression.

RESULTS

Of 643 patients, illicit drug use was identified in 12%. Acute kidney injury developed in 51%, and 5% required renal replacement therapy. Compared to the rest of the cohort, patients who used illicit drugs were younger and had higher peak serum creatine kinase, and developed a higher severity of acute kidney injury. In multivariable analysis, the factors associated with acute kidney injury were illicit drug use, peak creatine kinase, cardiovascular disease, concurrent sepsis and a clinically-evident pressure injury. Chronic kidney disease and need for fasciotomy were additional risk factors for renal replacement therapy.

CONCLUSIONS

Illicit drug use was associated with acute kidney injury and renal replacement therapy independent of creatine kinase levels.

Non-traumatic and non-drug-induced rhabdomyolysis

Rhabdomyolysis (RM), a fortunately rare disease of the striated muscle cells, is a complication of non-traumatic (congenital (glycogen storage disease, discrete mitochondrial myopathies and various muscular dystrophies) or acquired (alcoholic myopathy, systemic diseases, arterial occlusion, viral illness or bacterial sepsis)) and traumatic conditions. Additionally, RM can occur in some individuals under specific circumstances such as toxic substance use and illicit drug abuse. Lipid-lowering drugs in particular are capable of causing RM. This comprehensive review will focus on non-traumatic and non-drug-induced RM. Moreover, the pathology of RM, its clinical manifestation and biochemical effects, and finally its management will be discussed.

Pigment Nephropathy: Novel Insights into Inflammasome-Mediated Pathogenesis

Pigment nephropathy is an acute decline in renal function following the deposition of endogenous haem-containing proteins in the kidneys. Haem pigments such as myoglobin and haemoglobin are filtered by glomeruli and absorbed by the proximal tubules. They cause renal vasoconstriction, tubular obstruction, increased oxidative stress and inflammation. Haem is associated with inflammation in sterile and infectious conditions, contributing to the pathogenesis of many disorders such as rhabdomyolysis and haemolytic diseases. In fact, haem appears to be a signalling molecule that is able to activate the inflammasome pathway. Recent studies highlight a pathogenic function for haem in triggering inflammatory responses through the activation of the nucleotide-binding domain-like receptor protein 3 (NLRP3) inflammasome. Among the inflammasome multiprotein complexes, the NLRP3 inflammasome has been the most widely characterized as a trigger of inflammatory caspases and the maturation of interleukin-18 and -1β. In the present review, we discuss the latest evidence on the importance of inflammasome-mediated inflammation in pigment nephropathy. Finally, we highlight the potential role of inflammasome inhibitors in the prophylaxis and treatment of pigment nephropathy.

How to do it: investigate exertional rhabdomyolysis (or not)

Rhabdomyolysis is the combination of symptoms (myalgia, weakness and muscle swelling) and a substantial rise in serum creatine kinase (CK) >50 000 IU/L; there are many causes, but here we specifically address exertional rhabdomyolysis. The consequences of this condition can be severe, including acute kidney injury and requirement for higher level care with organ support. Most patients have ‘physiological’ exertional rhabdomyolysis with no underlying disease; they do not need investigation and should be advised to return to normal activities in a graded fashion. Rarely, exertional rhabdomyolysis may be the initial presentation of underlying muscle disease, and we review how to identify this much smaller group of patients, who do require investigation.

Acute kidney injury in trauma patients

PURPOSE OF REVIEW

To review epidemiology and pathophysiology of acute kidney injury (AKI) in trauma patients and propose strategies that aim at preventing AKI after trauma.

RECENT FINDINGS

AKI in trauma patients has been reported to be as frequent as 50% with an association to a prolonged length of stay and a raise in mortality. Among the specific risk factors encountered in trauma patients, hemorrhagic shock, rhabdomyolysis severity, age, and comorbidities are independently associated with AKI occurrence. Resuscitation with balanced solutes seems to have beneficial effects on renal outcome compared with NaCl 0.9%, particularly in the context of rhabdomyolysis. However, randomized clinical studies are needed to confirm this signal. Abdominal compartment syndrome (ACS) is rare but has to be diagnosed to initiate a dedicated therapy.

SUMMARY

The high incidence of AKI in trauma patients should lead to early identification of those at risk of AKI to establish a resuscitation strategy that aims at preventing AKI.

Delayed presentation of severe rhabdomyolysis leading to acute kidney injury following atorvastatin-gemfibrozil combination therapy: a case report

Background

Rhabdomyolysis is a rare but serious complication of lipid-lowering therapy. Statin and fibrate combination increases the risk of rhabdomyolysis possibly by pharmacodynamic interactions. Advanced age, diabetes, hypothyroidism, polypharmacy, and renal impairment are known to increase the risk of rhabdomyolysis. Management strategies include fluid resuscitation and urine alkalinization. Renal indications such as refractory hyperkalemia, acidosis, fluid overload, or uremic complications mandate renal replacement therapy in rhabdomyolysis.

Case presentation

We report the case of a 62-year-old Sri Lankan Sinhalese man with dyslipidemia, type 2 diabetes mellitus with renal impairment, and hypothyroidism who was on atorvastatin; he was started on gemfibrozil and developed muscle symptoms. Although gemfibrozil was discontinued soon after, he presented with rhabdomyolysis with acute kidney injury 1 month later. He needed hemodialysis due to refractory hyperkalemia, metabolic acidosis, and fluid overload.

Conclusions

Rhabdomyolysis is a rare but serious complication due to lipid-lowering therapy with statins and fibrates. Treating physicians should be aware and patients should be warned to report about muscle symptoms after starting statins or fibrates. Rhabdomyolysis may occur with mild symptoms and signs and may occur later, even after discontinuation of the drug.

The Outcome of Patients Presenting with Crush Syndrome after the Marmara Earthquake

In this study, we evaluated the clinical and laboratory data of the patients presenting after the Marmara earthquake. Crush syndrome was diagnosed in 60 patients (30 M, 30 F, mean age: 31.3±13.8 years). They were buried under the rubble for a mean period of 12.3±15.1 hours. On admission, 27 patients were oligoanuric and the mean serum creatinine, creatinine phosphokinase and potassium levels were 4.4±3.2 mg/dl, 18453.1±24527.2 IU/L, and 4.9±1.7 mEq/L, respectively. The most frequent site of trauma was the lower extremity. Dialysis treatment was initiated in 40 patients (19 M, 21 F, mean age: 32.7±13.0 years). Mean number of hemodialysis sessions/patient was 8.9±6.8. Nine (23%) patients among the dialyzed and 4 (20%) among the non-dialyzed died leading to an overall mortality of 21.6%. This low mortality rate suggests that the death rate from acute renal failure due to crush syndrome could be decreased by extensive follow-up.

Evaluation of Myoglobin Clearance during Continuous Hemofiltration in a Swine Model of Acute Renal Failure

Rhabdomyolysis is characterized by extensive damage of striated muscle, while the major complication of this disease is the development of acute myoglobinuric renal failure. Although first described more than five decades ago very little has changed with regard to the management of this entity as conventional hemodialysis has not been shown to effect myoglobin elimination. However, continuous arteriovenous hemofiltration (CAVH) offers an alternative to conventional hemodialysis as this procedure is more effective particularly for removing larger molecular weight substances such as myoglobin. We studied the effect of CAVH on myoglobin clearance in an animal model of acute myoglobinuric renal failure. Swine (n=6) were given 4 grams of equine myoglobin intravenously and underwent the CAVH procedure for six hours each. Once the filtering process was initiated there was a rapid and sustained production of ultrafiltrate. The clearance of myoglobin via the hemofilter was 2.05 ± 1.48 L/day. The amount of myoglobin excreted in the ultrafiltrate over the six hour filtering period was 410 ± 234 mg which accounts for 10.27 ± 5.85 percent of the administered dose. Based on these findings, it appears that the hemofiltration system is a viable option for the removal of myoglobin from the systemic circulation.

Myoglobin Clearance during Continuous Veno-Venous Hemofiltration with or without Dialysis

The management of acute myoglobinuric renal failure, the major complication of rhab-domyolysis, continues to be a treatment dilemma for the clinician as limited therapeutic options are available. Previously, we have demonstrated that continuous arteriovenous hemofiltration (CAVH) is an effective technique for removing myoglobin in an animal model. In the present study, swine were administered four grams of equine myoglobin intravenously and underwent the continuous veno-venous hemofiltration (CVVH) procedure for six hours each. Animals were studied in each of the following groups: CVVH at a pump rate 100 ml/minute, CVVH at a pump rate 200 ml/minute and CVVH at a pump rate 100 ml/minute plus dialysis at a dialysate flow rate of one Liter/h. Once the filtering process was initiated there was a rapid and sustained production of ultrafiltrate in all groups. The amount of myoglobin excreted in the ultrafiltrate over the six-hour filtering period was 688, 948 and 570 mg which corresponded to 17, 24 and 14 percent of the administered dose, respectively, for the three treatments. In comparison to previous CAVH experiments, CVVH removed more circulating myoglobin and the addition of the dialysis component did not appear to improve removal. Based on these findings, it appears that the CVVH hemofiltration system is a viable option for the removal of systemic myoglobin.

Fluids for Prevention and Management of Acute Kidney Injury

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.

Acute Kidney Injury (AKI)

Kidneys perform a multitude of essential functions within the human body. Of these the most important are (1) maintaining pH through regulation of acid/base levels and (2) excreting end products of metabolism. As for most organ-systems, these functions are especially important for healing following trauma and/or surgery and decline with age. Acute Kidney Injury (AKI) is one of the common forms of organ failures seen in the ICU and elderly patients are more prone to it. The causes maybe classified as Prerenal (inadequate perfusion), renal (inherent kidney disease) and post-renal (urinary obstruction). Preventing AKI should be an important concern in all critically ill patients but especially important in the elderly patients since the development of AKI can significantly increase in-hospital mortality. Once AKI has set in a systematic and step-wise approach of diagnosis and management is key to avoiding adverse outcomes.

Clinical and laboratory findings of rhabdomyolysis in opioid overdose patients in the intensive care unit of a poisoning center in 2014 in Iran

OBJECTIVES

The aim of this study was to investigate the clinical and demographic characteristics and some laboratory findings of hospitalized patients with acute opioid toxicity and rhabdomyolysis.

METHODS

This cross-sectional study investigated 354 patients hospitalized at Baharloo Hospital in Tehran in 2014 with acute illicit drug toxicity. Data were collected using an investigator-made checklist. The collected data (such as mortality rate, demographic data, and renal function tests, as well as serum biochemical findings) were analyzed by descriptive statistics and the chi-square test.

RESULTS

A total of 354 patients were admitted to the hospital in 2014 with acute illicit drug toxicity, including 291 males and 63 females. The total number of patients with rhabdomyolysis was 76 (21.5% of the total), of whom 69 (90.8%) were male and 7 (9.2%) were female. Most cases of rhabdomyolysis were associated with methadone abuse, followed by opium abuse. Rhabdomyolysis was most common in those 20-29 and 30-39 years old, with methadone and opium the most commonly abused illicit drugs. The mean blood urea level was 3.8±1.0 mg/dL, and the mean serum potassium and sodium levels were 3.8±0.3 mg/dL and 140.4±4.0 mg/dL, respectively. Five patients, all of whom were male, passed away due to severe renal failure (6.5%).

CONCLUSIONS

Toxicity caused by opioids is associated with clinical complications and laboratory disorders, such as electrolyte disorders, which can lead to lethal or life-threatening results in some cases. Abnormal laboratory test findings should be identified in patients with opioid toxicity in order to initiate efficient treatment.

Myoglobin facilitates angiotensin II-induced constriction of renal afferent arterioles

Vasoconstriction plays an important role in the development of acute kidney injury in rhabdomyolysis. We hypothesized that myoglobin enhances the angiotensin II (ANG II) response in afferent arterioles by increasing superoxide and reducing nitric oxide (NO) bioavailability. Afferent arterioles of C57Bl6 mice were isolated perfused, and vasoreactivity was analyzed using video microscopy. NO bioavailability, superoxide concentration in the vessel wall, and changes in cytosolic calcium were measured using fluorescence techniques. Myoglobin treatment (10−5 M) did not change the basal arteriolar diameter during a 20-min period compared with control conditions. NG-nitro-l-arginine methyl ester (l-NAME, 10−4 M) and l-NAME + myoglobin reduced diameters to 94.7 and 97.9% of the initial diameter, respectively. Myoglobin or l-NAME enhanced the ANG II-induced constriction of arterioles compared with control (36.6 and 34.2%, respectively, vs. 65.9%). Norepinephrine responses were not influenced by myoglobin. Combined application of myoglobin and l-NAME further facilitated the ANG II response (7.0%). Myoglobin or l-NAME decreased the NO-related fluorescence in arterioles similarly. Myoglobin enhanced the superoxide-related fluorescence, and tempol prevented this enhancement. Tempol also partly prevented the myoglobin effect on the ANG II response. Myoglobin increased the fura 2 fluorescence ratio (cytosolic calcium) during ANG II application (10−12 to 10−6 M). The results suggest that the enhanced afferent arteriolar reactivity to ANG II is mainly due to a myoglobin-induced increase in superoxide and associated reduction in the NO bioavailability. Signaling pathways for the augmented ANG II response include enhanced cytosolic calcium transients. In conclusion, myoglobin may contribute to the afferent arteriolar vasoconstriction in this rhabdomyolysis model.

Early Therapeutic Intervention for Crush Syndrome: Characterization of Intramuscular Administration of Dexamethasone by Pharmacokinetic and Biochemical Parameters in Rats

Crush syndrome (CS) is the systemic manifestation of muscle cell damage resulting from pressure and crushing. It is associated with a high mortality rate, even when patients are treated with conventional therapy. We demonstrated the utility of intramuscular administration of dexamethasone (DEX) in disaster medical care by using a model of CS to characterize the pharmacokinetics and biochemical parameters. We compared intravenous (IV) and intramuscular (IM) injection. The IM sites were the right anterior limb (AL), bilateral hind limbs (bHL), and unilateral hind limb (uHL). DEX (5.0 mg/kg) was administered in sham-operated (sham, S-IV, S-AL, S-bHL, S-uHL groups) and CS rats (control, C-IV, C-AL, C-bHL, C-uHL groups). The survival rate in the IM groups was lower than that in the C-IV group. Survival was highest in the C-AL group, followed by the C-uHL and C-bHL groups. The blood DEX concentration of the C-AL group was similar to that in the C-IV group. The C-bHL and C-uHL groups had decreased blood DEX concentrations. Moreover, inhibition of inflammation was related to these changes. Administration of DEX to non-injured muscle, as well as IV administration, increased the survival rate by modulating shock and inflammatory mediators, consequently suppressing myeloperoxidase activity and subsequent systemic inflammation, resulting in a complete recovery of rats from lethal CS. These results demonstrate that injection DEX into the non-injured muscle is a potentially effective early therapeutic intervention for CS that could easily be used in transport to the hospital.

An ignored cause of red urine in children: rhabdomyolysis due to carnitine palmitoyltransferase II (CPT-II) deficiency

Carnitine palmitoyltransferase II (CPT-II) deficiency is an autosomal recessively inherited disorder involving the β-oxidation of long-chain fatty acids, which leads to rhabdomyolysis and subsequent acute renal failure. The clinical phenotype varies from a severe infantile form to a milder muscle form. Here, we report a 9-year-old boy referred to our hospital for the investigation of hematuria with a 2-day history of dark urine and malaise. As no erythrocytes in the microscopic examination of the urine and hemoglobinuria were present, myoglobinuria due to rhabdomyolysis was the most probable cause of dark urine. After excluding the other causes of rhabdomyolysis, with the help of metabolic investigations, the patient was suspected to have CPT-II deficiency, the most common cause of metabolic rhabdomyolysis. Our aim in presenting this case is to emphasize considering rhabdomyolysis in the differential diagnosis of dark urine in order to prevent recurrent rhabdomyolysis and renal injury.

Acute Renal Failure and the Critically Ill Patient

Acute renal failure (ARF) is a complication frequently observed in critically ill patients. This review provides details regarding the epidemiology and overall care of the ARF patient. ARF is defined and classified based on etiology. These classifications are prerenal azotemia, ischemic ARF, and postrenal azotemia. Examples of drug-induced nephrotoxicity are also outlined. Clinical presentation and diagnostic criteria of ARF are differentiated among the major ARF classes, and management strategies are outlined. These management strategies include preventive, supportive, pharmacologic, and nonpharmacologic interventions. Current standards of practice and investigational therapies are also discussed. Pharmacokinetic monitoring and dosing regimen adjustments in ARF patients with and without renal replacement therapy are reviewed. Finally, a prognostic evaluation of ARF in critically ill patients is provided based on current knowledge of the disease state and treatment options.

Compartment syndrome causes systemic inflammation in a rat

Aims

Compartment syndrome results from increased intra-compartmental pressure (ICP) causing local tissue ischaemia and cell death, but the systemic effects are not well described. We hypothesised that compartment syndrome would have a profound effect not only on the affected limb, but also on remote organs.

Methods

Using a rat model of compartment syndrome, its systemic effects on the viability of hepatocytes and on inflammation and circulation were directly visualised using intravital video microscopy.

Results

We found that hepatocellular injury was significantly higher in the compartment syndrome group (192 PI-labelled cells/10-1 mm3, standard error of the mean (sem) 51) compared with controls (30 PI-labelled cells/10-1 mm3, sem 12, p < 0.01). The number of adherent venular white blood cells was significantly higher for the compartment syndrome group (5 leukocytes/30s/10 000 μm2, sem 1) than controls (0.2 leukocytes/30 s/10 000 μm2, sem 0.2, p < 0.01). Volumetric blood flow was not significantly different between the two groups, although there was an increase in the heterogeneity of perfusion.

Conclusions

Compartment syndrome can be accompanied by severe systemic inflammation and end organ damage. This study provides evidence of the relationship between compartment syndrome in a limb and systemic inflammation and dysfunction in a remote organ. Cite this article: Bone Joint J 2016; 98-B:1132–7.

Bicarbonate and mannitol treatment for traumatic rhabdomyolysis revisited

BACKGROUND

A rhabdomyolysis protocol (RP) with mannitol and bicarbonate to prevent acute renal dysfunction (ARD, creatinine >2.0 mg/dL) remains controversial.

METHODS

Patients with creatine kinase (CK) greater than 2,000 U/L over a 10-year period were identified. Shock, Injury Severity Score, massive transfusion, intravenous contrast exposure, and RP use were evaluated. RP was initiated for a CK greater than 10,000 U/L (first half of the study) or greater than 20,000 U/L (second half). Multivariable analyses were used to identify predictors of ARD and the independent effect of the RP.

RESULTS

Seventy-seven patients were identified, 24 (31%) developed ARD, and 4 (5%) required hemodialysis. After controlling for other risk factors, peak CK greater than 10,000 U/L (odds ratio 8.6, P = .016) and failure to implement RP (odds ratio 5.7, P = .030) were independent predictors of ARD. Among patients with CK greater than 10,000, ARD developed in 26% of patients with the RP versus 70% without it (P = .008).

CONCLUSION

Reduced ARD was noted with RP. A prospective controlled study is still warranted.

[Pharmacokinetics characteristics of dexamethasone in Crush syndrome model rats]

Crush syndrome (CS) is characterized by ischemia/reperfusion-induced rhabdomyolysis and subsequent systemic inflammation and has a high mortality rate, even when treated with conventional therapy. In previous studies, we demonstrated that treatment of rats with acute lethal CS using dexamethasone (DEX) had therapeutic effects in laboratory findings and improved the clinical course of CS. However, because the application of DEX in CS therapy is unknown, evaluation of the pharmacokinetic parameters of DEX was considered essential to support its clinical use. Here, we investigated the pharmacokinetic characteristics of DEX in a rat model of CS. Anesthetized rats were subjected to bilateral hind limb compression using rubber tourniquets for 5 h, followed by reperfusion for 0 to 24 h. Rats were divided randomly into 4 groups: saline-treated sham (S) and CS groups and 5.0 mg/kg DEX-treated S (S-DEX) and CS (CS-DEX) groups. Blood and tissue samples were collected for HPLC analysis. In the CS-DEX group, the pharmacokinetic parameters of the area under the concentration-time curve, mean residence time, and distribution volume levels increased significantly compared to the S-DEX group, whereas total body clearance, elimination rate constant, and renal clearance levels decreased significantly. Moreover, decrease of muscle tissue DEX concentration and of CYP3A activity were observed in the CS-DEX group. These results show the pharmacokinetic characteristics of DEX in the rat CS model and support the potential use of DEX in disaster medical care.

Rhabdomyolysis and acute kidney injury in the injured war fighter

BACKGROUND

Rhabdomyolysis is a recognized complication of traumatic injury. The correlation of an elevated creatine kinase (CK) level and the development of acute kidney injury (AKI) has been studied in the civilian population. We sought to review the prevalence of rhabdomyolysis in injured war fighters and determine if peak CK levels correlate with AKI.

METHODS

This is a retrospective cohort study of patients admitted at a US military treatment facility from January to November 2010. Inclusion criteria were active duty patients transported after explosive, penetrating, or blunt injury. Patients with burns or non-trauma-related admissions were excluded. Rhabdomyolysis was defined as a CK level greater than 5,000 U/L. AKI was defined using the Kidney Disease: Improving Global Outcomes classification. Mann-Whitney U-tests were used to determine the significance for continuous data. Correlations were determined using Spearman's ρ. Significance was set at p < 0.05.

RESULTS

Of the 318 patients included in our analysis, 310 (98%) were male, and the median age was 24 years (21-28 years). Blast was the predominant mechanism of injury (71%), with a median Injury Severity Score (ISS) of 22 (16-29). Rhabdomyolysis developed in 79 patients (24.8%). The median peak CK for all patients was 4,178 U/L and ranged from 208 U/L to 120,000 U/L. Stage 1, 2, and 3 AKI developed in 56 (17.6%), 3 (0.9%), and 7 (2.2%) patients, respectively. There was a weak but statistically significant correlation between peak CK and AKI (r = 0.26, p < 0.05).

CONCLUSION

Elevated peak CK levels in the injured war fighter are weakly associated with the development of AKI but are not predictive. The development of clinical practice guidelines would help standardize treatment for rhabdomyolysis in combat casualties and would allow for standardized comparisons in future work.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Red Kidney: Kidney Transplant From a Deceased Donor Who Received Massive Blood Transfusion During Cardiopulmonary Bypass

Here, we present a case of a deceased-donor kidney transplant. The brain-dead donor had received a massive blood transfusion during cardiopulmonary bypass, which lead to hemolysis, hemoglobinuria, acute kidney injury, and renal replacement therapy. The kidney appeared red after in situ flush. Postoperatively, the recipient developed delayed graft function. Protocol biopsy during the postoperative period revealed the widespread deposition of heme pigment in the renal tubules. Massive blood transfusion and cardiopulmonary bypass surgery are associated with hemolysis and heme pigment deposition in the renal tubules, which subsequently lead to acute kidney injury. Kidneys from such donors appear red and, while this does not preclude transplant, are likely to develop delayed graft function.

Disaster nephrology: a new concept for an old problem

Natural and man-made mass disasters directly or indirectly affect huge populations, who need basic infrastructural help and support to survive. However, despite the potentially negative impact on survival chances, these health care issues are often neglected by the authorities.

Treatment of both acute and chronic kidney diseases (CKDs) is especially problematic after disasters, because they almost always require complex technology and equipment, whereas specific drugs may be difficult to acquire for the treatment of the chronic kidney patients. Since many crush victims in spite of being rescued alive from under the rubble die afterward due to lack of dialysis possibilities, the terminology of ‘renal disaster’ was introduced after the Armenian earthquake. It should be remembered that apart from crush syndrome, multiple aetiologies of acute kidney injury (AKI) may be at play in disaster circumstances.

The term ‘seismonephrology’ (or earthquake nephrology) was introduced to describe the need to treat not only a large number of AKI cases, but the management of patients with CKD not yet on renal replacement, as well as of patients on haemodialysis or peritoneal dialysis and transplanted patients. This wording was later replaced by ‘disaster nephrology’, because besides earthquakes, many other disasters such as hurricanes, tsunamis or wars may have a negative impact on the ultimate outcome of kidney patients.

Disaster nephrology describes the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances and also to avoid post-disaster chaos, which can be made possible by preparing medical and logistic scenarios. Learning and applying the basic principles of disaster nephrology is vital to minimize the risk of death both in AKI and CKD patients.

Fatal Rhabdomyolysis following Spine Surgery in a Morbidly Obese Patient: A Case Report

We generally believe that obese patients are faced on higher risk of developing perioperative complications. Rhabdomyolysis is a rare but potentially life-threatening condition caused by the release of injured skeletal muscle components into the circulation. It usually results from mechanical damage to the muscle, intoxication, or a postictal state after a seizure. In the present study, we have reported a rare case of rhabdomyolysis developing in a morbidly obese patient after upper thoracic spinal fusion surgery. We have found acute renal failure that evolved during the course of treatment resulted in a fatal outcome even though the patient received intensive supportive care. Our experience suggests that this rare complication should be considered in morbidly obese patients and those efforts should be made to avoid rhabdomyolysis.

Rhabdomyolysis in Obese Trauma Patients

Patients sustaining traumatic injuries are at risk for development of rhabdomyolysis. The effect of obesity on this risk is unknown. This study attempted to characterize the role of obesity in the development of rhabdomyolysis after trauma. This was a retrospective review of all trauma patients with creatine kinase (CK) levels admitted to the surgical intensive care unit (SICU) at a Level I trauma center from February 2011 until July 2013. Patients were divided based on their body mass index (BMI): overweight/obese group with BMI 25 kg/m2 or greater and nonoverweight/obese group with BMI less than 25 kg/m2. Primary outcome was CK greater than 10,000 U/L. During the 30-month study period, 198 trauma patients with available CK levels were admitted to the SICU. The majority (27.8%) of patients were involved in a motor vehicle collision. There were 96 patients (48.4%) with BMI 25 kg/m2 or greater and 102 (51.5%) with BMI less than 25 kg/m2. There was no difference in creatinine levels between the two groups (1.5 ± 1.2 mg/dL vs 1.5 ± 1.4 mg/dL, P = 0.83). BMI 25 kg/m2 or greater was independently associated with the development of CK greater than 10,000 U/L (14.6 vs 4.9%; adjusted odds ratio, 3.03; P = 0.04). Patients with BMI 25 kg/m2 or greater are at a significantly higher risk for rhabdomyolysis after trauma. Aggressive CK level monitoring to prevent rhabdomyolysis in this population is strongly encouraged.

Pheniramine Maleate-Induced Rhabdomyolysis and Aki: Is it Fatal?

Pheniramine maleate is an easily accessible, over-the-counterantihistaminic, which is frequently involved in overdoses. Pheniramine has antimuscarinic effect causing tachycardia, dilated pupils, urinary retention, and dry flushed skin, and decreased bowel sounds, confusion, mild increase in body temperature, cardiac arrhythmias, and seizures at lethal doses. It has not been implicated as an important cause of rhabdomyolysis and acute kidney injury (AKI). Rhabdomyolysis causing AKI is rarely reported in the literature. This case report emphasizes the occurrence of nontraumatic rhabdomyolysis in pheniramine maleate overdose which required hemodialysis. Since there is a lack of a specific antidote, treatment is mainly symptomatic and supportive. We report a fatal case of a young male with a very high dose of consumption of pheniramine maleate (4.077 g), which was complicated by seizures, respiratory depression, nontraumatic rhabdomyolysis, and AKI. Despite hemodialysis, ventilator support, and other intensive supportive care, patient could not survive and death ensued due to multiorgan dysfunction syndrome.

[Perioperative acute kidney injury and failure]

Perioperative period is very likely to lead to acute renal failure because of anesthesia (general or perimedullary) and/or surgery which can cause acute kidney injury. Characterization of acute renal failure is based on serum creatinine level which is imprecise during and following surgery. Studies are based on various definitions of acute renal failure with different thresholds which skewed their comparisons. The RIFLE classification (risk, injury, failure, loss, end stage kidney disease) allows clinicians to distinguish in a similar manner between different stages of acute kidney injury rather than using a unique definition of acute renal failure. Acute renal failure during the perioperative period can mainly be explained by iatrogenic, hemodynamic or surgical causes and can result in an increased morbi-mortality. Prevention of this complication requires hemodynamic optimization (venous return, cardiac output, vascular resistance), discontinuation of nephrotoxic drugs but also knowledge of the different steps of the surgery to avoid further degradation of renal perfusion. Diuretics do not prevent acute renal failure and may even push it forward especially during the perioperative period when venous retourn is already reduced. Edema or weight gain following surgery are not correlated with the vascular compartment volume, much less with renal perfusion. Treatment of perioperative acute renal failure is similar to other acute renal failure. Renal replacement therapy must be mastered to prevent any additional risk of hemodynamic instability or hydro-electrolytic imbalance.