Acute renal impairment after immersion and near-drowning

Near-drowning: new perspectives for human hypoxic acute kidney injury

Concepts regarding hypoxic acute kidney injury (AKI) are derived from widely used warm ischemia-reflow (WIR) models, characterized by extensive proximal tubular injury and associated with profound inflammation. However, there is ample clinical and experimental data indicating that hypoxic AKI may develop without total cessation of renal blood flow, with a different injury pattern that principally affects medullary thick limbs in the outer medulla. This injury pattern likely reflects an imbalance between blood and oxygen supply and oxygen expenditure, principally for tubular transport. Experimental models of hypoxic AKI other than WIR are based on mismatched oxygen delivery and consumption, particularly within the physiologically hypoxic outer medulla. However, evidence for such circumstances in human AKI is lacking. Recent analysis of the clinical course and laboratory findings of patients following near-drowning (ND) provides a rare glimpse into such a scenario. This observation supports the role of renal hypoxia in the evolution of AKI, as renal impairment could be predicted by the degree of whole-body hypoxia (reflected by lactic acidosis). Furthermore, there was a close association of renal functional impairment with indices of reduced oxygen delivery (respiratory failure and features of intense sympathetic activity) and of enhanced oxygen consumption for active tubular transport (extrapolated from the calculated volume of consumed hypertonic seawater). This unique study in humans supports the concept of renal oxygenation imbalance in hypoxic AKI. The drowning scenario, particularly in seawater, may serve as an archetype of this disorder, resulting from reduced oxygen delivery, combined with intensified oxygen consumption for tubular transport.

Acute Renal Failure Following Near-Drowning

Introduction

Acute kidney injury associated with near-drowning (ND-AKI) has rarely been reported and its incidence among survivors is unknown. A patient with AKI and urine biomarkers indicating tubular injury led us to assess the occurrence and clinical characteristics of ND-AKI and to evaluate possible causative mechanisms.

Methods

We evaluated medical records of patients rescued from near-drowning in the Mediterranean Sea and treated in a tertiary-level medical center during 2000 to 2017.

Results

Ninety-five patients with the diagnosis of near-drowning in seawater were treated. Forty-two of these patients (43%) developed ND-AKI and 17 (18%) were classified as AKI Kidney Disease: Improving Global Outcomes stages 2 to 3. ND-AKI was associated with the need for resuscitation and mechanical ventilation, with the calculated seawater volume ingestion (extrapolated from rising plasma sodium) and with the degree of acidemia, lactemia, and ventilatory failure. This series and 28 additional published cases of ND-AKI in the literature showed an overall male predisposition.

Conclusion

AKI is a common complication of near-drowning and is associated with increased in-hospital mortality. Data analysis suggests a predominant role of hypoxic tubular injury due to systemic hypoxemia in ND-AKI, combined with intense sympathetic activity (reflected by tachyarrhythmias, hyperglycemia, and relative hypokalemia) and increased oxygen expenditure for intensified distal tubular sodium transport. Androgen-related reduced renal vasodilatory capacity may explain male gender predominance.

Acute kidney injury after near drowning: The way from the beach to hemodialysis

Acute kidney injury (AKI) occurs in many different situations and may have a variable prognosis influenced by clinical setting, underlying cause, and comorbidity. This is important because of the high mortality and morbidity risk affecting many people around the world. Near-drowning related AKI requiring hemodialysis is very seldom reported in literature. Although cardiovascular and respiratory disorders are more frequently seen after this entity, we aimed to emphasize this rare but dangerous complication in near-drowning patients.

A case of severe acute kidney injury by near-drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.

Drowning

PURPOSE OF REVIEW

To summarize current knowledge on pathophysiology and treatment of drowning accidents. Studies and case reports were searched using the keywords drowning, near-drowning, asphyxia, hypoxia and hypothermia in conjunction with organ systems and specific treatment options.

RECENT FINDINGS

Drowning is defined as death by suffocation in a liquid. In contrast, near-drowning is defined as survival beyond 24 h after a drowning accident. Drowning is a frequent preventable accident with a significant morbidity and mortality in a mostly healthy population. In the majority of patients the primary injury is pulmonary, resulting in severe arterial hypoxemia and secondary damage to other organs. Damage to the central nervous system is most critical in terms of patient survival and subsequent quality of life. Therefore, prompt resuscitation and aggressive respiratory and cardiovascular treatment are crucial for optimal survival. Immediate interruption of hypoxia, aggressive treatment of hypothermia and cardiovascular failure are the cornerstones of correct medical treatment. Unfortunately, accurate neurologic prognosis cannot be predicted from initial clinical presentation, laboratory, radiological or electrophysiological examinations.

SUMMARY

Several case studies have convincingly demonstrated that drowning victims may survive neurologically intact even after prolonged submersion times, in particular in cold water. Therefore, aggressive initial therapeutic efforts are indicated in most near-drowning victims.

Drowning and near-drowning

Water immersion is a frequent cause of accidental death and hospital admission. This article outlines the pathogenesis and principles of treatment. Drowning is defined as death by asphyxia due to submersion in a liquid medium. Near-drowning is defined as immediate survival after asphyxia due to submersion.