Original ContributionClinical factors in predicting acute renal failure caused by rhabdomyolysis in the ED
Introduction
Rhabdomyolysis is characterized by skeletal muscle breakdown with leakage of muscle contents, including electrolytes, myoglobin, and other sarcoplasmic proteins (eg, creatine kinase, lactate dehydrogenase, alanine aminotransferase, and aspartate aminotransferase) into the circulation [1], [2]. The major causes include trauma, ischemia, exertion, drugs, toxins, metabolic disorders, electrolyte disorders, and infections [2], [3], [4], [5]. Typically, patients with rhabdomyolysis present with muscle pain, weakness, and reddish-brown urine caused by myoglobinuria. Nevertheless, the severity of rhabdomyolysis varies from an asymptomatic increase in creatine phosphokinase (CK) to serious complications such as acute renal failure (ARF), cardiac arrhythmias, compartmental syndrome, hypovolemic shock, and disseminated intravascular coagulopathy [4], [5], [6], [7], [8], [9], [10].
Acute renal failure is the most important and serious complication of rhabdomyolysis. It has been reported that 10% to 40% of patients with rhabdomyolysis develop ARF and that 5% to 15% of cases of ARF are attributable to rhabdomyolysis [6]. However, in a larger study of 191 children with a CK level greater than 1000 U/mL who were sent to the emergency department (ED), the prevalence of ARF was 5%, with a requirement for renal replacement therapy (RRT) in 3 of the 9 patients with renal failure [11]. Preventing the progression to ARF and early detection of ARF appear to be important issues in rhabdomyolysis. However, it is still unclear which factors are highly correlated with ARF and how they can be used to predict ARF in patients with rhabdomyolysis. In this study, we analyzed the clinical spectrum of rhabdomyolysis in patients in the ED and attempted to determine the predictors for ARF and the risk factors for RRT. In addition, we aimed to establish the appropriate cutoff values of serum biomarkers in predicting ARF caused by rhabdomyolysis.
Section snippets
Materials and methods
This study was a single-center medical record review of patients 65 years or younger who presented to the ED with a diagnosis of rhabdomyolysis based on their medical histories and elevated serum CK levels (> 1000 IU/L) within 72 hours after admission to the ED. We reviewed the medical records of all eligible patients from January 2006 to December 2011. The study was approved by the institutional review board of Changhua Christian Hospital, and the necessity to obtain written consent was waived
Statistical analysis
Data of categorical variables were analyzed by the χ2 test or Fisher’s exact test, when appropriate. Continuous variables were analyzed by the Student’s t-test. A P value less than .05 was regarded as statistically significant. A multiple logistic regression model was then developed using the variables that were determined to be significantly associated with ARF. Distributions of variables were reported as percentages and means ± SD. Receiver operating characteristic (ROC) analysis was used to
Demographics and clinical presentations
During the 6-year study period, 202 patients (168 male and 34 female; mean age, 33.4 ± 16.3 years) who presented to the ED with rhabdomyolysis were enrolled. The 2 most common symptoms at presentation were muscle pain and muscle weakness (56.7% and 59.9%, respectively). Dark urine was found in 18.8% of the patients but appeared to be a more common symptom in the ARF group than in the non-ARF group (41.4% vs 15%, P = .001; Table 1).
Etiologies of the patients with rhabdomyolysis and ARF
Of the 202 patients with rhabdomyolysis, 190 (94.1%) had a
Discussion
Rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes. The classic findings of myalgia, muscle weakness, and tea-colored urine are nonspecific and may not always be present [4], [5], [6], [7], [8], [9], [10], [16]. In 2006, Mannix et al [12] showed that in a sample of 210 patients (age < 21 years), 45% presented with myalgia, 38% had muscle weakness, and only 3.6% had dark urine. Of the 202 patients (age ≦ 65 years) in the current study, myalgia and
Conclusions
Age, dark urine, etiology of rhabdomyolysis, serum levels of BUN, Cr and potassium, and initial and peak serum myoglobin levels may be important factors to indicate the patients with rhabdomyolysis that may develop ARF. The risk factors for required RRT included etiology of rhabdomyolysis, peak serum BUN level, peak serum Cr level, and the serum CK level on the third day of rhabdomyolysis development. We suggest that primary clinicians should be alert and prescribe aggressive medical management
Acknowledgments
The study was partly funded by grants from the Changhua Christian Hospital (101-CCH-IRP-29).
References (29)
- et al.
The syndrome of rhabdomyolysis: pathophysiology and diagnosis
Eur J Intern Med
(2007) - et al.
The other medical causes of rhabdomyolysis
Am J Med Sci
(2003) - et al.
The syndrome of rhabdomyolysis: complications and treatment
Eur J Intern Med
(2008) Rhabdomyolysis and myohemoglobinuric acute renal failure
Kidney Int
(1996)- et al.
Peak value of blood myoglobin predicts acute renal failure induced by rhabdomyolysis
J Crit Care
(2010) - et al.
Renal failure secondary to acute tubular necrosis: epidemiology, diagnosis, and management
Chest
(2005) - et al.
Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis
Am J Emerg Med
(2005) - et al.
Rhabdomyolysis: a review
Muscle Nerve
(2002) - et al.
Rhabdomyolysis and acute kidney injury
N Engl J Med
(2009) - et al.
Rhabdomyolysis
Intern Emerg Med
(2007)
Pathogenesis of renal failure in rhabdomyolysis: the role of myoglobin
Exp Nephrol
Rhabdomyolysis and myoglobinuria
Nervenarzt
Acute renal failure and rhabdomyolysis
Int J Artif Organs
Rhabdomyolysis: an evaluation of 475 hospitalized patients
Medicine (Baltimore)
Cited by (41)
Urine proteomics as a non-invasive approach to monitor exertional rhabdomyolysis during military training
2022, Journal of ProteomicsCitation Excerpt :The appearance of muscle pain, changes in sensitivity, muscle weakness, dark brown urine, myalgia, and edema of body segments are classic symptoms for RM [10,11]. The main consequences of RM may be associated with acute renal failure, electrolytic disorder, cardiac arrhythmia, compartment syndrome, and eventually death [12–14]. The incidence of RM by physical exertion is approximately 30 for every 100,000 patients per year [15,16].
Extremity compartment syndrome
2018, Current Problems in SurgeryCitation Excerpt :Rhabdomyolysis occurs when myoglobin from damaged muscle spills into plasma, causing damage, and occlusion of renal tubules. This leads to renal ischemia and acute kidney injury (AKI) in 10% to 55% of patients.60-62 Additionally, the significant cytokine release associated with rhabdomyolysis causes swelling which may exacerbate an unreleased compartment syndrome.
Non-traumatic rhabdomyolysis: Background, laboratory features, and acute clinical management
2017, Clinical BiochemistryCitation Excerpt :As a consequence, blood levels remain increased longer than for myoglobin, which has a half-life of 2–4 h. Myoglobin values tend to normalize within 6–8 h following the event [17,84,85]. Strong evidence has emerged that peak values of myoglobin in serum or plasma could be better predictors of AKI than CK values [86–89]. These data have been recently supported by a meta-analysis of 18 studies, concluding that AKI occurrence was significantly predicted by CK value in patients with crush-induced rhabdomyolysis, but not in those with other causes of rhabdomyolysis [90].
Novel Biomarkers for the Assessment of the Cardio-Renal Syndrome—A Paradigm Shift
2023, Journal of Clinical Medicine