Acute renal failure related to the crush syndrome: towards an era of seismo-nephrology?

Management of kidney injury in critically ill patients with earthquake-induced crush syndrome: A case series of 18 patients

İNTRODUCTION: It was aimed primarily to analyze the development of acute kidney injury (AKI) and treatment management in critically ill patients who developed rhabdomyolysis due to earthquake-related crush syndrome.

METHODS

We evaluated 18 patients with crush syndrome who were admitted to the intensive care unit (ICU) after the great earthquake in February 2023 in Turkey.

RESULTS

AKI occurred in 83% (n:15) of these patients after ICU admission (AKI-1; 16.6% [n:3], AKI-2; 16.6% [n:3], and AKI-3; 50% [n:9]). While the majority of patients who developed crush syndrome were treated with high volume intravenous hydration, only 33% (n:6) of all patients required renal replacement therapy. All patients who developed AKI had complete recovery in renal functions at the end of 2 months.

CONCLUSION

There is no need for routine renal replacement therapy in the treatment of AKI, which is frequently seen in patients with crush syndrome. Most can be treated with high volumes of intravenous fluid.

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.

A Novel Non-Contact Detection and Identification Method for the Post-Disaster Compression State of Injured Individuals Using UWB Bio-Radar

Building collapse leads to mechanical injury, which is the main cause of injury and death, with crush syndrome as its most common complication. During the post-disaster search and rescue phase, if rescue personnel hastily remove heavy objects covering the bodies of injured individuals and fail to provide targeted medical care, ischemia-reperfusion injury may be triggered, leading to rhabdomyolysis. This may result in disseminated intravascular coagulation or acute respiratory distress syndrome, further leading to multiple organ failure, which ultimately leads to shock and death. Using bio-radar to detect vital signs and identify compression states can effectively reduce casualties during the search for missing persons behind obstacles. A time-domain ultra-wideband (UWB) bio-radar was applied for the non-contact detection of human vital sign signals behind obstacles. An echo denoising algorithm based on PSO-VMD and permutation entropy was proposed to suppress environmental noise, along with a wounded compression state recognition network based on radar-life signals. Based on training and testing using over 3000 data sets from 10 subjects in different compression states, the proposed multiscale convolutional network achieved a 92.63% identification accuracy. This outperformed SVM and 1D-CNN models by 5.30% and 6.12%, respectively, improving the casualty rescue success and post-disaster precision.

Host-Derived Cytotoxic Agents in Chronic Inflammation and Disease Progression

At inflammatory sites, cytotoxic agents are released and generated from invading immune cells and damaged tissue cells. The further fate of the inflammation highly depends on the presence of antagonizing principles that are able to inactivate these host-derived cytotoxic agents. As long as the affected tissues are well equipped with ready-to-use protective mechanisms, no damage by cytotoxic agents occurs and resolution of inflammation is initiated. However, long-lasting and severe immune responses can be associated with the decline, exhaustion, or inactivation of selected antagonizing principles. Hence, cytotoxic agents are only partially inactivated and contribute to damage of yet-unperturbed cells. Consequently, a chronic inflammatory process results. In this vicious circle of permanent cell destruction, not only novel cytotoxic elements but also novel alarmins and antigens are liberated from affected cells. In severe cases, very low protection leads to organ failure, sepsis, and septic shock. In this review, the major classes of host-derived cytotoxic agents (reactive species, oxidized heme proteins and free heme, transition metal ions, serine proteases, matrix metalloproteases, and pro-inflammatory peptides), their corresponding protective principles, and resulting implications on the pathogenesis of diseases are highlighted.

[Myorenal syndrome in forensic practice: molecular aspects of etiology and pathogenesis]

The objective of the study is to analyze the publications on biochemical aspects of myorenal syndrome (crush-syndrome) pathogenesis. Factors of trauma and other etiologies significant in terms of forensic practice that cause muscle tissue destruction are presented. Molecular processes in rhabdomyolysis and subsequent renal damage, the establishment of the sequence of which is important for forensic medicine, are outlined. The study results will improve our understanding of the of myorenal syndrome pathophysiology, its biochemical features, and optimize methods for its forensic diagnosis.

International Conference: "Renal Aspects of Disaster Relief", Ohrid, R. Macedonia, May 24-26, 1996

The International Conference Renal Aspects of Disaster Relief, Ohrid, R. Macedonia, May 24-26, 1996 united doctors and engineers in order to better build settlements, and in case of an earthquake, how to help the injured.Plans have been proposed for the treatment of the injured with fluid and dialysis, as well as how to organize the non-governmental organizations and the population to assist the medical staff in optimizing the treatment of the injured.Members of the Renal Disaster Relief Task Force of the International Society of Nephrology and the European Renal Best Practice were tasked with preparing guidelines for medical staff and the population to address earthquake injuries.

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.

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.

Myoglobin Mediates Autophagy of NRK-52E in Rat Renal Tubular Epithelial Cells Via the Pink1/Parkin Signaling Pathway

Background

The aim of this study was to investigate whether myoglobin mediates the autophagy of NRK-52E via the Pink1/Parkin signaling pathway.

Material/Methods

Differentially-expressed genes were selected by PCR chip analysis of the autophagy signaling pathway. RT-PCR and Western blot analyses were used to detect the expressions of Pink1/Parkin and autophagy-related proteins in myoglobin-treated NRK-52E. LC3 double-labeled lentivirus was used to infect NRK-52E for observing autophagy. The role of myoglobin mediates autophagy was evaluated through Pink1-siRNA inhibition of the Pink1/Parkin signaling pathway.

Results

Myoglobin acted on NRK-52E, caused differential expressions of Pink1, Parkin, and Beclin 1, increased apoptosis, and decreased cell viability. myoglobin increased the levels of Pink1, Beclin 1 and ATG5, decreased the levels of P62 and Parkin. The level of LC3II/LC3I showed significant elevation in NRK-52E cells at after incubated with 100 μmol/L myoglobin. Inhibiting Pink1/Parkin signaling pathway through Pink1-siRNA could alleviate myoglobin induced apoptosis, decrease the levels of Pink, Beclin1, ATG5, LC3II/LC3I, and elevate the levels of Parkin and P62. Moreover, the autophagy spots were reduced after silencing Pink1 in myoglobin-treated NRK-52E.

Conclusions

Myoglobin mediates the autophagy of NRK-52E in rat renal tubular epithelial cells via the Pink1/Parkin signaling pathway.

Effect of Hydrogen Sulfide on Kidney Injury in Rat Model of Crush Syndrome

BACKGROUND

Acute kidney injury is the most serious complication of crush syndrome. Hydrogen sulfide (H₂S) is an endogenously produced gaseous signaling molecule. It is involved in homeostatic functions, such as blood pressure control, apoptosis, oxidative stress, and inflammation. In this study, effects of H₂S on kidney injury were investigated in a rat model of crush syndrome.

METHODS

Rats were divided into six groups (n = 8): Sham (steril saline ip), crush (sterile saline ip), crush + NaHS (sodium hydrosulfide, an H₂S donor) (100 μmol/kg ip). All these groups were also separated as 3 and 24 h after decompression. Crush injury was induced by 6 h of direct compression to both hindlimbs of anesthetized rats with blocks weighing 3.6 kg each sides, followed by 3 or 24 h of decompression. Kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, tumor-necrotizing factor-α, transforming growth factor-β, tissue total oxidant status, and total antioxidant status levels were measured in kidney homogenates 3 and 24 h after decompression. Serum creatine kinase, blood urea nitrogen, and creatinine levels were also measured. Apoptosis was assessed by TUNEL method. Bcl-2 was assessed by immunohistochemistry. Glomerular and tubular structures were also examined histopathologically.

RESULTS

NaHS reduced kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, tumor-necrotizing factor-α, transforming growth factor-β, total oxidant status levels, and increased total antioxidant status levels in kidney 3 and 24 h after decompression. Serum urea, creatinine, and creatine kinase levels also reduced with NaHS. NaHS decreased renal damage and apoptosis in crush-related acute kidney injury.

CONCLUSIONS

These results suggest that H₂S could reduce crush-related acute kidney injury via anti-inflammatory, antioxidant, and antiapoptotic effects.

Systemic Inflammatory Response and Multiple Organ Dysfunctions Following Crush Injury: a New Experimental Model in Rabbits

In this study, we aim to develop a new, reproducible crush injury (CI) model in rabbits. Anesthetized rabbits were compressed on both hind limbs using a special instrument for 6 h followed by 3 h of reperfusion. Blood samples and injured muscles were collected for biochemical analysis and morphological evaluation. Survival observation lasted for 72 h. Bilateral compressions with 10 kg/kg body weight (BW), but not with 5 kg/kg BW, reduced serious systemic impairment. Bilateral compressions with 10 kg/kg BW resulted in severe lactic acidosis; increased serum K⁺, creatine phosphokinase, aspartate transaminase, alanine transaminase, blood urea nitrogen, and creatinine levels; and a sharply decreased mean arterial blood pressure after compression release. Serious tissue edema and inflammation were observed in the damaged muscles. The mortality rates in compression groups were 20% (5 kg/kg BW) and 60% (10 kg/kg BW). There was a significant increase in plasma concentrations of TNF-α and IL-1β after compression. Plasma IL-1β levels returned to control levels at 6 h after compression release, whereas TNF-α peaked at 12 h following reperfusion. Furthermore, antiinflammatory cytokines, including IL-4 and IL-10, were also increased after compression, and these two cytokines peaked at 12 h after compression release. Our data suggested that bilateral compression with 10 kg/kg BW on rabbits' hind limbs is a reproducible CI model, and we also reported the CI-induced systemic inflammatory responses and changes of cytokines over time.

Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.

Crush Syndrome after the Wenchuan Earthquake: New Experience with Regional Citrate Anticoagulation Continuous Veno-Venous Hemofiltration

Purpose

Acute renal failure (ARF) related to crush syndrome is usually treated with hemodialysis. Continuous veno-venous hemofiltration (CVVH) has seldom been adopted in this situation due to the main drawback of continuous anticoagulation. The purpose of this study was to evaluate the effectiveness and safety of regional citrate anticoagulation (RCA)-CVVH in two crush syndrome patients following the Wenchaun earthquake.

Methods

Two victims from the Wenchuan earthquake in Southwest China were admitted to our hospital on May 23, 2008, 11 days after their injury. The total entrapment time under the rubble was 5.5 and 22.5 hrs respectively. They remained oliguric on admission, in spite of vigorous treatment in the local hospital including aggressive fluid infusion, fasciotomy and intermittent hemodialysis. On admission, their serum myoglobin levels were 765 and 829 ng/mL, respectively. Further debridement and drainage were performed. RCA-CVVH was conducted; the citrate containing substitution fluid was infused in a pre-dilution manner at a rate of 4 l/h; calcium was infused through a separate access to the venous inlet of the double lumen catheter. The infusion rate was adjusted according to the serum ionized calcium and whole blood activated clotting time (WBACT). A low dose of low molecular weight heparin (LMWH) was infused at the rate of 150∼300 U/h simultaneously for anticoagulation after anemia had been corrected and their wounds were stable. RCA-CVVH was substituted by conventional CVVH and LMWH anticoagulation when case 2 complicated with hypoxia.

Results

RCA-CVVH was well tolerated, hemodynamic status was stable, and no complications related with RCA-CVVH were noted. The body temperature and WBC decreased to normal range, while anemia and hypoalbuminia were corrected. The levels of serum myoglobin and creatine phosphokinase were also decreased to normal range. Their urine volume increased after 20 and 22 days of oliguria and the tubular function of the patients recovered well. Although the second case encountered acute cholecystitis and acute lung injury in the hospital, both the patients recuperated and neither of them underwent amputation.

Conclusions

The present two crush patients have been successfully treated, but due to the limits of the small sample, it is difficult to generalize whether RCA-CVVH is safe enough for crush syndrome with a high risk of bleeding diathesis. Additional investigation with a larger number of patients is required. Fluid equilibrium, nutritional support, prevention of bleeding and infection are fundamental in this situation.

A Systematic Review of Iranian Experiences in Seismo-Nephrology

Context

Crush syndrome and its potentially life-threatening complications, such as acute kidney injury (AKI), are one of the most important medical problems of disaster victims. However, today, many unanswered questions abound about the potential risk factors of crush syndrome, predictive factors of AKI, proper amount of prophylactic hydration therapy, type of fluid, time of continuing fluid, intravenous versus oral hydration, etc. Therefore, this study was designed to review the findings on Iranian nephrologist experiences in diagnosis and management of traumatic rhabdomyolysis following the last two strong earthquakes of Bam (2003) and Manjil-Rudbar (1990).

Evidence Acquisition

The study was conducted according to the MOOSE reporting guideline. A literature review was conducted on the nephrologic aspects of earthquakes in Iran. Relevant articles were identified through a comprehensive search of online databases until 2014. The search was limited to articles studying the Iranian population published in English and Persian languages. The validated combination of MeSH terms and key words was used. In addition, a manual search was run among the references of all articles that met the entrance criteria and previous reviews. Only cohort, case-control, and cross-sectional studies were enrolled. Two reviewers independently reviewed the eligible studies, and another reviewer contributed in case of a disagreement. Basic information from each study was evaluated from the aspects of purpose and design, year of publication, methodology, main population, and source of data. The quality of the included studies was assessed using methods guide for effectiveness and comparative effectiveness reviews. Two reviewers independently rated each paper as “good”, “fair”, or “poor”.

Results

A total of 1256 non-duplicate articles were identified, but only 35 potentially relevant papers were screened. Finally, 21 articles were found eligible and studied in details. In addition, one unpublished report was included. In the quality assessment, two articles had poor quality, and thus only 20 were finally included in the systematic review. No publication bias (coefficient = −2.28; 95% Confidence interval: −6.17 - 1.78; P = 0.26) was observed among the included studies.

Conclusions

A few eligible articles on seismo-nephrology were found in Iran, and a limited number of current articles had poor or fair quality. As expected, the chaotic situation after mass disasters and the lack of documentation led to the loss of much important data on the diagnosis and management of victims. Lessons learned from the current researches can be used as a valuable guide for future studies.

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.

Management of crush victims in mass disasters: highlights from recently published recommendations

Crush syndrome is the second most common cause of death after earthquakes (the first most common is direct trauma). Many logistic problems with the treatment of patients with crush syndrome are due to chaotic disaster circumstances; consequently, medical and logistic recommendations on the treatment of crush victims are needed. In a joint initiative of the Renal Disaster Relief Task Force of the International Society of Nephrology and European Renal Best Practice, a work group of nephrologists, intensivists, surgeons, and logisticians with disaster experience or experts in guideline preparation collaborated to provide comprehensive information and recommendations on the management of crush casualties considering their occurrence with "epidemic" dimensions after mass disasters. The result is the monograph "Recommendations for the Management of Crush Victims in Mass Disasters", which may help provide effective health care to disaster victims with renal problems. This article discusses medical and logistic principles of the treatment of crush victims, both at the disaster field and on admission to hospitals, and guidance is described. The importance of early fluid administration even before extrication of the victims and avoidance of potassium-containing solutions during the treatment of crush victims is underlined. Also, the logistic problems in treating crush casualties are emphasized. The most important aspects of the recently published recommendations are highlighted.

Predictive factors for acute renal failure in crush injuries in the Sichuan earthquake

INTRODUCTION

The Sichuan earthquake caused a large number of crush injuries and many of them developed acute renal failure (ARF). A retrospective study was performed on victims with crush injuries of West China Hospital to investigate the predictive factors for acute renal failure (ARF) in crush injuries.

PATIENTS AND METHODS

Medical records of injured victims treated in West China Hospital within the first week after the Sichuan earthquake were retrospectively reviewed and 101 patients with crush injury were enrolled in the study. We divided them into an ARF group and a non-ARF group. The clinical data of included patients were extracted and analysed.

RESULTS

Patients with ARF accounted for 42% of the included population. Patients younger than 20 made up the biggest age category (45%), and the entrapped time under the debris (22 [IQR 3.5-38]h) was longer than previous reports. In univariate analysis, male gender, multiple crush injuries, medical comorbidities, surgical interventions and infections were more frequent in patients with ARF than in those without ARF. Mean arterial pressure was higher in the ARF group. Besides, the risk of ARF was increased by creatine kinase >14,494.5IU/L most significantly, followed by time under the rubble >4h, aspartate transaminase >453.5IU/L, albumin <27.15g/L and white blood cell >11.8×10(9)/L. In multivariate analysis, male gender, time under the rubble, multiple crush injuries, surgical interventions, infections and creatine kinase level were independently associated with ARF in crush injuries.

CONCLUSIONS

The entrapped time under the debris, multiple crush injuries, male gender, infections, and creatine kinase level are predictive factors for ARF in crush injuries.

Preventive effects of hyperbaric oxygen treatment on glycerol-induced myoglobinuric acute renal failure in rats

Myoglobinuric acute renal failure (ARF) is a uremic syndrome caused by traumatic or non-traumatic skeletal muscle breakdown and intracellular elements that are released into the bloodstream. We hypothesized that hyperbaric oxygen (HBO) therapy could be beneficial in the treatment of myoglobinuric ARF caused by rhabdomyolysis. A total of 32 rats were used in the study. The rats were divided into four groups: control, control+hyperbaric oxygen (control+HBO), ARF, and ARF+hyperbaric oxygen (ARF+HBO). Glycerol (8 ml/kg) was injected into the hind legs of each of the rats in ARF and ARF+HBO groups. 2.5 atmospheric absolute HBO was applied to the rats in the control+HBO and ARF+HBO groups for 90 min on two consecutive days. Plasma urea, creatinine, sodium, potassium, calcium, aspartate aminotransferase, alanine aminotransferase, lactic dehydrogenase, creatinine kinase and urine creatinine and sodium were examined. Creatinine clearance and fractional sodium excretion could then be calculated. Superoxide dismutase, catalase, glutathione and malondialdehyde (MDA) levels were assessed in renal tissue. Tissue samples were evaluated by Hematoxylin-eosin, PCNA and TUNEL staining histopathologically. MDA levels were found to be significantly decreased whereas SOD and CAT were twofold higher in the ARF+HBO group compared to the ARF group. Renal function tests were ameliorated by HBO therapy. Semiquantitative evaluation of histopathological findings indicated that necrosis and cast formation was decreased by HBO therapy and TUNEL staining showed that apoptosis was inhibited. PCNA staining showed that HBO therapy did not increase regeneration. Ultimately, we conclude that, in accordance with our hypothesis, HBO could be beneficial in the treatment of myoglobinuric ARF.

Levels of neutrophil gelatinase-associated lipocalin in 2 patients with crush syndrome after a mudslide

Neutrophil gelatinase-associated lipocalin is one of the most promising biomarkers for the diagnosis of acute kidney injury. An increase in the level of neutrophil gelatinase-associated lipocalin is a good predictor of acute kidney injury and is associated with an increase in the serum level of creatinine. Two victims of a mudslide in Messina, Italy, initially had crush syndrome followed by development of acute kidney injury. The development of acute kidney injury is the second most common cause of death after large earthquakes and other natural disasters, but at the same time, crush-related acute kidney injury is one of the few life-threatening complications of crush injuries that can be reversed if diagnosed early and treated. In this case, measuring the level of neutrophil gelatinase-associated lipocalin enabled early diagnosis of acute kidney injury and anticipation of the changes in levels of conventional markers such as creatinine.

Crush syndrome and acute kidney injury in the Wenchuan Earthquake

BACKGROUND

The Wenchuan Earthquake resulted in calamitous destruction and massive death. We report the characteristics of crush syndrome (CS) and acute kidney injury (AKI) brought by the earthquake, which took place in a mountainous area.

METHODS

We conducted a cross-section survey of total 2,316 consecutive admissions because of seismic trauma, of which 1,827 had complete data available after we excluded those victims with mild injuries. The characteristics of CS and AKI in the mountainous earthquake were analyzed.

RESULTS

A total of 149 patients (8.2%) were diagnosed with CS. They had various complications, including different kinds of infection or sepsis, AKI, hematological abnormality, adult respiratory distress syndrome, congestive heart failure, multiple organs dysfunction syndrome, etc. The incidence of hyperkalemia was 15.9% in patients with CS. The hyperkalemia relapsed in five patients after hemodialysis in the first 3 days. AKI occurred in 62 patients (41.6% of CS patients) with CS and 33 of them received renal replacement therapy. In our hospital, 5 of them died. The overall mortality rate was 1.0% and mortality of patients with CS was 6.7%. Twelve patients (50%) died in the first 3 days.

CONCLUSIONS

Although the mountains hampered rescue actions, causing more loss of life, CS and AKI were still common and life-threatening events in the Wenchuan Earthquake. Most patients with CS and/or AKI had severe complications, especially hyperkalemia.

Acute Kidney Injury Due to Rhabdomyolysis in Narcotic Drug Users

Background

Regular or illegal drugs and toxins are the most frequent non-physical causes of rhabdomyolysis (RM) in peacetime. Acute Kidney Injury (AKI) is a serious and, sometimes, fatal complication of RM. It occurs in 8–20% of RM incidents.

Methods

In this prospective study we evaluated the severity of RM and AKI in narcotic drug users. From January 2001 to December 2007, 21 patients (17 males, mean age 27.8±4.8 years) with RM associated with AKI were classified into two groups: 11 heroin users (HU) and 10 non-heroin users (NHU). The severity of RM was evaluated by estimation, on admission, of serum creatine phosphokinase (CPK), serum glutamic oxaloacetic transaminase (SGOT), lactate dehydrogenase (LDH), phosphate (PO4) and calcium (Ca) and by the presence of paraplegia (PPL). The severity of AKI during hospitalization was evaluated by estimation of serum creatinine (CR), the presence of oligoanuria (OA), the days of hospitalization (DH), the total of hemodialysis treatments (THD) and the number of patients who received blood transfusions (BT).

Results

RM was much more severe in HU than in NHU. Mean SGOT, CPK, LDH, and P values on admission were higher in HU. Hypocalcemia was statistically more severe in HU. Nine HU were admitted with PPL vs. 1 NHU. Serum CR levels were higher and oligoanuria was much more common in HU. HU had a longer hospitalization period and underwent a bigger number of HT. More HU took BT.

Conclusions

The results of this study suggest that both RM and ARF are more severe in HU than in NHU possibly due to an additional myotoxic effect of heroin.

Prophylactic fluid therapy in crushed victims of Bam earthquake

BACKGROUND

Acute kidney injury (AKI) is a severe and preventable problem of crushed earthquake victims. Early hydration therapy started before fully removing earthquake rubbles has been claimed to play a decisive role in AKI prevention, which saves the necessity of later dialysis. However, the extent, quality, and appropriateness of its know-how are controversial.

METHODS

Processing clinical and paraclinical data gathered from Bam earthquake victims older than 15 years, we tried to determine correlations between the time of being under the rubbles (TUR), the level of serum creatine phosphokinase (CPK), the delayed onset of fluid therapy (DFT), and finally the volume of intravenous fluid received per day (VFR) with the formation of AKI and the need for dialysis.

RESULTS

There is a direct and significant relation between the intensity of the trauma (TUR and CPK) and DFT with the occurrence of AKI and need for dialysis (P < .001). However, as the VFR increases, the occurrence of AKI and the need for dialysis significantly decrease (P = .005). Based on multivariate analysis, the occurrence of AKI and the need for dialysis are primarily affected by CPK, TUR, and VFR; and DFT has been dropped out. The analysis showed the preventive role of VFR more than 6 L in severe rhabdomyolysis patients and of at least 3 L in moderate ones in development of AKI and dialysis.

CONCLUSIONS

In the severely rhabdomyolized patients (CPK ≥ 15,000), higher volumes of prophylactic fluid (VFR >6 L) are required, whereas in less-traumatized patients, lower volumes (3-6 L) would be effective.

Malnutrition and inflammation in acute kidney injury due to earthquake-related crush syndrome

Background

Malnutrition and inflammation are common and serious complications in patients with acute kidney injury (AKI). However, the profile of these complications in patients with AKI caused by crush syndrome (CS) remains unclear. This study describes the clinical characteristics of malnutrition and inflammation in patients with AKI and CS due to the Wenchuan earthquake.

Methods

One thousand and twelve victims and eighteen healthy adults were recruited to the study. They were divided into five groups: Group A was composed of victims without CS and AKI (904 cases); Group B was composed of patients with CS and AKI who haven't received renal replacement therapy (RRT) (57 cases); and Group C was composed of patients with CS and AKI receiving RRT (25 cases); Group D was composed of earthquake victims with AKI but without CS (26 cases); and Group E was composed of 18 healthy adult controls. The C-reactive protein (CRP), prealbumin, transferrin, interleukin-6 and TNF-α were measured and compared between Group E and 18 patients from Group C.

Results

The results indicate that participants in Group C had the highest level of serum creatinine, blood urea nitrogen and uric acid. Approximately 92% of patients with CS who had RRT were suffering from hypoalbuminemia. The interleukin-6 and CRP levels were significantly higher in patients with CS AKI receiving RRT than in the control group. Patients in Group C received the highest dosages of albumin, plasma or red blood cell transfusions. One patient in Group C died during treatment.

Conclusions

Malnutrition and inflammation was common in patients with earthquake-related CS and had a negative impact on the prognosis of these subjects. The results of this study indicate that the use of RRT, intensive nutritional supplementation and transfusion alleviated the degree of malnutrition and inflammation in hemodialysis patients with crush syndrome.

Renal disaster relief in Europe: the experience at L'Aquila, Italy, in April 2009

On 6 April 2009, an earthquake struck the city of L'Aquila and the surrounding Abruzzo mountains. The disaster left 66,000 people homeless, while 1500 were wounded and 298 died. Although Europe as a whole is not so often affected by massive earthquakes, Italy is an exception with 12 earthquakes with an intensity >6.0 on the Richter scale during the last 100 years. This article offers preliminary information on the L'Aquila earthquake. For the time being, nine AKI patients who needed dialysis treatment are known. In all of them, kidney function recovered. This positive result can be attributed to the efficient and intensive rescue efforts coupled to the availability of disaster plans that had been developed in advance. This article stresses the importance of (i) advance planning of disaster rescue; (ii) the inclusion in these plans of approaches for kidney problems and their complications; (iii) the formulation of recommendations supporting (para-)medical professionals in their preventive, therapeutic and logistic approach to massive incidences of crush.

Renal replacement therapy in support of combat operations

BACKGROUND

Renal replacement therapy has been used by the U.S. Army at the combat support hospital echelon of care since the Korean conflict. Although there has been a general decline in the incidence of wartime acute kidney injury, the mortality associated with acute kidney injury and the use of renal replacement therapy remain unchanged, in the range of 60% to 80%. The U.S. Army official doctrine is that field dialysis is provided through a specialized Hospital Augmentation Team; however, this team has not been deployed to either Iraq or Afghanistan as a result of the ability to rapidly evacuate most cases requiring renal replacement therapy. The history of wartime renal replacement therapy is reviewed along with the general epidemiology of battlefield acute kidney injury and renal replacement therapy.

DISCUSSION

Recent literature documents cases of renal replacement therapy performed in and out of theater in support of the current operations. In-theater renal replacement therapy has been provided through a variety of modalities, including conventional hemodialysis, peritoneal dialysis, and both continuous venovenous and continuous arteriovenous hemodialysis. Out of theater, casualties have received both intermittent and continuous hemodialysis at Landstuhl Regional Medical Center and Walter Reed Army Medical Center, whereas patients sustaining burns have undergone aggressive continuous venovenous hemofiltration or hemodiafiltration at Brooke Army Medical Center.

SUMMARY

Acute kidney injury requiring renal replacement therapy in wartime casualties is an uncommon occurrence but one with extremely high mortality. Future doctrine should be prepared for contingencies in which the incidence may be increased as a result of mass crush injury casualties or prolonged evacuation times.

Rhabdomyolysis

Rhabdomyolysis is the disintegration of striated muscles resulting in the release of muscular cell contents into the extracellular fluid. Crush syndrome is systemic manifestations caused by rhabdomyolysis; the most important component of crush syndrome is acute kidney injury. Non-physical and physical causes play a role in the aetiology of rhabdomyolysis. Clinical spectrum varies from asymptomatic elevation in creatine kinase to acute tubular necrosis and multiorgan failure. Myoglobinuria, increased serum creatine kinase level and hyperkalaemia are the most important laboratory parameters. Vigorous hydration with isotonic saline followed by alkaline solutions and mannitol are useful in the treatment of rhabdomyolysis.

Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya

BACKGROUND

Crush syndrome developing as a result of earthquake and other natural disasters has been investigated from many angles to date. Data are scarce, however, on cases associated with the spontaneous crash of buildings. This study presents the results on seven rhabdomyolysis patients treated in our clinics out of nine casualties who were rescued from the rubble of Zümrüt apartment after the building collapsed suddenly and spontaneously.

METHODS

As a result of the sudden, spontaneous collapse of the 10-floor Zümrüt apartment in Konya at 20:15 hours on February 2, 2004, 92 out of a total of 121 persons who were inside the building lost their lives, and 29 casualties were rescued from the rubble. Nine hospitalized patients had crush syndrome, and a prophylactic mannitol-bicarbonate cocktail was started in all at admission.

RESULTS

The time they remained entrapped under the rubble was 11.1 +/- 7.3 (5-24 hours) on average. The highest CPK level of the patients was 79049 +/- 75374 u/L (17478-223600 u/L), observed on the median day 1.7 +/- 1.1 (days 1-4) following the incident. ARF developed in only two cases (28.6%) owing to the prophylactic mannitol-bicarbonate cocktail administered to prevent ARF, and because of hyperpotassemia, hemodialysis (HD) treatment was administered to these patients. One patient required two sessions of HD, and another required four. In both patients who received HD treatment, the level of potassium was in excess of 7 mEq/L. A total of eight fasciotomies were performed on five (71.4%) of the seven patients with crush syndrome. Five of the fasciotomies (62.5%) were performed on two of our patients who required HD treatment. None of our patients with crush syndrome developed permanent kidney damage, and no mortality occurred.

CONCLUSION

It was deduced that rapid fluid therapy accompanied by the prophylactic administration of mannitol-bicarbonate are largely effective in preventing the development of ARF in cases with crush syndrome resulting from disasters.

Nephrology in earthquakes: sharing experiences and information

Earthquakes are the most unpredictable natural disasters and often result in many deaths and casualties as a result in part of the collapse of buildings. To restore medical facilities and activities after a large earthquake, nephrologists play critical roles not only in the restoration of dialysis facilities for regular renal replacement therapy but also in the prevention and treatment of acute kidney injury and hyperkalemia, mainly as a result of crush syndrome. For these purposes, sufficient education and establishment of functional networks among medical facilities are certainly needed. Recently, the contribution of international task forces has become more significant, especially for large-scale natural disasters. Organized detailed action plans should be prepared among regional governments and armies considering the differences in cultures and social systems.

The effect of combining intermittent hemodiafiltration with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis

BACKGROUND

Our aim was to examine the effect of combining intermittent hemodiafiltration (HDF) with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis.

METHODS

This was a prospective, randomized, controlled, cross-over study. Sixteen rhabdomyolysis patients with plasma myoglobin concentrations above 10,000 microg/l were randomized. Forced alkaline diuresis was started immediately after allocation and continued throughout the study. HDF, which lasted for 4 h, was started in group A immediately after allocation and in group B 4 h later. The primary analysis was intention-to-treat by repeated measures analysis of variance and Mann-Whitney U-test.

RESULTS

The percentage elimination of myoglobin from the circulation during HDF differed significantly from that during alkaline diuresis (28.1% vs. 14.2%, respectively; P < 0.01). The mean decrease in plasma myoglobin concentration during HDF [9731 microg/l; 95% confidence interval (CI), 3672-5345 microg/l] and forced alkaline diuresis (3646 microg/l; 95% CI, 1260-6032 microg/l) did not show a statistically significant difference (P= NS). The mean total amount of myoglobin found in the ultrafiltrate was 58.4 mg.

CONCLUSION

The percentage myoglobin decrease during combined HDF and forced alkaline diuresis was higher than that during forced alkaline diuresis alone. Renal replacement therapy with filtration techniques may be considered for the clearance of myoglobin from plasma when urine alkalinization is not successful.

Rhabdomyolysis caused by hypernatremia

Rhabdomyolysis is a clinical picture which is rarely seen in children. In this case report here it is presented a patient who has biochemical and clinical signs of rhabdomyolysis and admitted to our clinic with hypernatremia. The authors think that it is necessary to be alert for rhabdomyolysis in severe hypernatremia cases.

Rhabdomyolysis and acute renal failure associated with influenza virus type B infection

A patient with rhabdomyolysis-induced acute renal failure due to influenza B virus infection is presented. Influenza B infection caused rhabdomyolysis with efflux of myoglobin from myocytes, causing acute renal failure. In conclusion, influenza virus type B can cause severe rhabdomyolysis leading to acute renal failure.

Electronic strategies for information and research: cyberNephrology/cyberMedicine in the emerging world

Communication and medicine have evolved together. Internet resources now provide an unprecedented opportunity to provide health assistance to the developing world. The International Society of Nephrology Informatics Commission and National Kidney Foundation cyberNephrology initiative (http://www.cybernephrology.org) have created e-mail discussion groups (e.g., NEPHROL, NEPHKIDS, and so forth) and online texts and web resources (e.g., the Schrier Atlas: http://www.kidneyatlas.org) that are, in many respects, ahead of other areas of medicine. On the other hand, nephrology is quite behind in its embrace of some specific communications initiatives that could benefit emerging nations: the Health InterNetwork Access to Research Initiative program, which provides free full-text access to medical journals and books in poorer countries; the Global Health Network Supercourse, which provides specially designed online lectures for the developing world; and Internet2/Abilene and similar research networks around the world, which provide reliable, guaranteed bandwidth for high-quality Internet videoconferencing as an alternative to face-to-face lectures and meetings. The intent of many educational ventures in nephrology, particularly in the clinical practice guideline realm (National Kidney Foundation Kidney Disease Outcomes Quality Initiative, Kidney Disease Improving Global Outcomes, and so forth), is not just to disseminate information but to change human behavior: physician practice and referral patterns, patient compliance, and so forth. Concepts from the worlds of marketing and entertainment, where the science of changing human behavior is highly evolved, can be used to create high-impact, educational offerings to promote health. They can also be highly beneficial to share Internet educational innovations and future vision across boundaries of medical specialties, which is part of the intent of the cyberMedicine joint venture (http://www.cyber-medicine.org).

[High doses statins administration causing rhabdomyolysis: case report]

Rhabdomyolysis has been the theme in medical literature for the last fifty years. In these last decades, with statins being used in primary and secondary cardiovascular prevention events, this theme returns and statins are now pointed as the trigger to this almost always fatal complication. Rhabdomyolysis due to statins administration occurs mainly in association with other drugs. Our case reports on a patient with fatal statin-induced rhabdomyolysis whose medical history included diffuse atherosclerotic disease.

Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians

Rhabdomyolysis ranges from an asymptomatic illness with elevation in the creatine kinase level to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure and disseminated intravascular coagulation. Muscular trauma is the most common cause of rhabdomyolysis. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, drugs, toxins and endocrinopathies. Weakness, myalgia and tea-colored urine are the main clinical manifestations. The most sensitive laboratory finding of muscle injury is an elevated plasma creatine kinase level. The management of patients with rhabdomyolysis includes early vigorous hydration.

Renal uptake of myoglobin is mediated by the endocytic receptors megalin and cubilin

Nephrotoxicity of myoglobin is well recognized as playing a part in the development of acute renal failure in settings of myoglobinuria. However, the molecular mechanism of myoglobin uptake in renal proximal tubules has not been clarified. Here, we report that the endocytic receptors megalin and cubilin are involved in renal reabsorption of myoglobin. Both receptors were captured from solubilized renal brush-border membranes by affinity chromatography using myoglobin-Sepharose. Myoglobin bound to purified megalin and cubilin with Kd values of 2.0 and 3 microM, respectively, as evaluated by surface plasmon resonance analysis. Apomyoglobin bound to megalin with the same affinity, and the affinity of apomyoglobin to cubilin was reduced (Kd = 5 microM). Radioiodinated myoglobin could be displaced by apomyoglobin in inhibition studies using isolated renal brush-border membranes (Ki approximately 2 microM). Receptor-associated protein as well as antibodies directed against megalin and cubilin markedly inhibited the uptake of fluorescent-labeled myoglobin by cultured yolk sac BN-16 cells. The significance of megalin- and cubilin-mediated endocytosis for myoglobin uptake in vivo was demonstrated by use of kidney-specific megalin knockout mice. Injected myoglobin was extensively reabsorbed by megalin-expressing proximal tubular cells, whereas there was very little uptake in the megalin-deficient cells. In conclusion, this study establishes the molecular mechanism of myoglobin uptake in the renal proximal tubule involving the endocytic receptors megalin and cubilin. Identification of the receptors for tubular uptake of myoglobin may be essential for development of new therapeutic strategies for myoglobinuric acute renal failure.

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

OBJECTIVE

To evaluate the risk factors for the development of acute renal failure (ARF) in severe rhabdomyolysis.

DESIGN

Observational historical cohort study.

SETTING

General intensive care unit of a university hospital.

PATIENTS

Twenty-six patients with severe rhabdomyolysis, who were admitted between July 1996 and July 2001.

MEASUREMENTS AND RESULTS

Clinical and laboratory data were reviewed and groups were stratified according to presence or absence of acute renal failure. The underlying cause of rhabdomyolysis was ischemia by vascular obstruction (50%), crush injury by trauma (23%), sepsis (11.5%), heatstroke/hyperthermia (11.5%) and hyponatremia in a single patient. Mean creatine kinase (CK) level was 38,351+/-35,354 U/l on admission and rose further in all patients (mean: 59,747+/-67,514 U/l). Renal failure developed in 17 patients (65%). Serum CK levels correlated with onset of ARF, as these patients had significantly higher admission and peak serum CK concentrations. Patients with ARF had a higher mortality (59% vs 22%).

CONCLUSION

In our cohort of patients with severe rhabdomyolysis the level of serum CK predicted the development of ARF. Although our results suggest that series of CK determination might be beneficial for the evaluation of the effect of therapy, the value of CK determination as a prognostic tool is limited, given the wide range of CK levels.

The organization and interventions of the ISN Renal Disaster Relief Task Force

This article describes first the organization of the ISN Renal Disaster Relief Task Force-European branch founded by the ISN Commission on ARF. The task force aims at rapid dialysis intervention in case of acute disasters associated with a high number of ARF cases caused by crush syndrome. The organization involves European volunteers consisting of nephrologists, dialysis nurses, and technicians willing to go to disaster areas as far as India, the Middle East, and North Africa to assist the local nephrologic communities. In addition, an important role in the organization is played by Médecins sans Frontiières, the industry, and several nurses' and technicians' associations. The major intervention of the task force was at the occasion of the Marmara earthquake in Turkey in 1999. Additional more recent and minor interventions occurred in India and Algeria.

Report of the International Society of Nephrology: North American Renal Disaster Response Task Force

This article comprises a report from the North American Renal Disaster Response Task Force (RDRTF) set up in 2001 by the International Society of Nephrology Acute Renal Failure Commission. The conclusions of the report are (1) given the rarity of renal disasters in the Americas the North American and Latin American RDRTF's should be merged; (2) for the same reason, a single RDRFT Coordination Center for the whole world should be established and it is suggested that this be in Ghent, Belgium; (3) the collaborative group set up in Europe and involving the European RDRTF and Medecins Sans Frontiers be asked to extend their rapid response service to cover acute renal disasters in the Americas south of the United States-Mexico border; (4) the combined RDRTF for the Americas should establish a list of nephrologists, nurses, and technicians who are available to assist in the acute response to renal disasters; (5) the combined RDRTF of the Americas establish an inventory of equipment, machines, and methods for their transport that would be available in the event of a disaster; and (6) the RDRTF of the Americas should undertake a large-scale educational initiative on management of renal disasters.