Objective: To describe patients presenting with acute kidney injury after rhabdomyolysis at a tertiary renal care center in Pakistan. Patients and Methods: An observational cohort of patients identified as having acute kidney injury (AKI) with rhabdomyolysis, which was diagnosed by rise in creatinine phosphokinase (CK) and lactate dehydrogenase (LDH) more than 4 times the reference range whereas AKI was defined according to RIFLE criteria. On ultrasonography, all patients had normal size non obstructed kidneys, and no other co morbid. Results: Between January1990 to December 2014, 334 patients with rhabdomyolysis and AKI registered to this hospital. Mean age was 28.22 ± 11.22 years with M:F ratio of 3.33:1. Mean values of CK and LDH were 597,749.790 ± 180,461.360 and 4077.026 ± 5050.704 U/L with reference range of 26 - 174 U/L and 91 - 180 U/L respectively. We divided the study population into 4 groups over timeline. Rhabdomyolysis etiology was divided in 3 groups; 1) traumatic, 2) non-traumatic exertional, and 3) non-traumatic non-exertional. In the last group, which spans from 2010-2014, we treated many cases with toxic rhabdomyolysis and main toxin was paraphenylenediamine (PPD). The other causes showed more or less same prevalence over two and a half decade, except non-traymatic exertional which has decreased during last 5 years without any explainable cause. Renal replacement therapy (RRT) was required on arrival in 94% cases. Complete renal recovery was observed in 70%, while 15.86% died and 10% were lost during recovery phase. A small number 2.69% left against medical advice during acute phase of illness and 0.8% developed chronic kidney disease (CKD). Conclusion: The common clinical conditions found associated with rhabdomyolysis and AKI includes trauma, immobilization, sepsis, overexertion, and drugs and toxins. In recent years, we have seen many young patients with PPD poisoning; we have found good renal recovery in patients who survived initial 2 - 3 weeks.
References
[1]
Miller, M.L. (2014) Clinical Manifestations and Diagnosis of Rhabdomyolysis. Up Todate, Version 11.0.
[2]
Giannoglou, G.D., Chatzizisis, Y.S. and Misirli, G. (2007) The Syndrome of Rhabdomyolysis: Pathophysiology and Diagnosis. European Journal of Internal Medicine, 18, 90. http://dx.doi.org/10.1016/j.ejim.2006.09.020
[3]
Khan, F.Y. (2009) Rhabdomyolysis: A Review of the Literature. Netherlands Journal of Medicine, 67, 272.
[4]
Bosch, X., Poch, E. and Grau, J.M. (2009) Rhabdomyolysis and Acute Kidney Injury. New England Journal of Medicine, 361, 62-72. http://dx.doi.org/10.1056/NEJMra0801327
[5]
Gabow, P.A., Kaehny, W.D. and Kelleher, S.P. (1982) The Spectrum of Rhabdomyolysis. Medicine (Baltimore), 61, 141-152. http://dx.doi.org/10.1097/00005792-198205000-00002
[6]
Melli, G., Chaudhry, V. and Cornblath, D.R. (2005) Rhabdomyolysis: An Evaluation of 475 Hospitalized Patients. Medicine (Baltimore), 84, 377. http://dx.doi.org/10.1097/01.md.0000188565.48918.41
[7]
Huerta-Alardín, A.L., Varon, J. and Marik, P.E. (2005) Bench-to-Bedside Review: Rhabdomyolysis—An Overview for Clinicians. Critical Care, 9, 158. http://dx.doi.org/10.1186/cc2978
[8]
Petejova, N. and Martinek, A. (2014) Acute Kidney Injury Due to Rhabdomyolysis and Renal Replacement Therapy: A Critical Review. Critical Care, 18, 224-231. http://dx.doi.org/10.1186/cc13897
[9]
Sheikh, I.A., Shaheen, F.A.M., El Aqeil, N., Alkhader, A. and Karsuwa, S. (1994) ARF Due to Rhabdomyolysis Following Human Setmpede. Saudi Journal of Kidney Diseases and Trans-plantation, 5, 17-22.
[10]
McMahon, G.M., Zeng, X. and Waikar, S.S. (2013) A Risk Prediction Score for Kidney Failure or Mortality in Rhabdomyolysis. JAMA Internal Medicine, 173, 1821. http://dx.doi.org/10.1001/jamainternmed.2013.9774
[11]
Lameire, N., Van Biesen, W. and Vanholder, R. (2006) Acute Renal Failure. The Lancet, 365, 417-430. http://dx.doi.org/10.1016/S0140-6736(05)70238-5
[12]
Book of Numbers: The Bible. The New English Bible (1970) Joint Comitee on the New Translation of the Bible. Cambridge University Press, New York, Vol. 11, 31-35.
[13]
Rizzi, D., Basile, C. and Di Maggio, A. (1991) Clinical Spectrum of Accidental Hemlock Poisoning: Neurologic Manifestations, Rhabdomyolysis and Acute Tubular Necrosis. Nephrology Dialysis Transplantation, 6, 939-943. http://dx.doi.org/10.1093/ndt/6.12.939
[14]
Vanholder, R., Sever, M.S., Erek, E. and Lameire, N. (2000) Rhabdomyolysis. Disease of the Month. Journal of the American Society of Nephrology, 11, 1553-1561.
[15]
Bywaters, E.G.L. and Beall, D. (1941) Crush Injuries with Impairment of Renal Function. British Medical Journal, 1, 427-432. http://dx.doi.org/10.1136/bmj.1.4185.427
[16]
Smith, L., Post, R., Teschan, P., Abernathy, R., Davis, J., Gray, D., Howard, J., Johnson, K., Klopp, E., Mundy, R., et al. (1955) Postraumatic Renal Insufficiency in Military Casualties. II Management, Use of an Artificial Kidney, Prognosis. American Journal of Medicine, 18, 187-198. http://dx.doi.org/10.1016/0002-9343(55)90234-5
[17]
Stone, W. and Knepshield, J. (1974) Post Traumatic Acute Renal Insufficiency in Vietnam. Clinical Nephrology, 2, 189-190.
[18]
Ward, M. (1988) Factors Predictive of Acute Renal Failure in Rhabdomyolysis. Archives of Internal Medicine, 148, 1553-1557. http://dx.doi.org/10.1001/archinte.1988.00380070059015
[19]
Mohaupt, M. (2003) Rhabdomyolysis. Therapeutische Umschau, 60, 391-397. http://dx.doi.org/10.1024/0040-5930.60.7.391
[20]
Splendiani, G., Mazzarella, V., Cipriani, S., Zazzaro, D. and Casciani, C. (2001) Dialytic Treatment of Rhabdomyolysis-Induced Acute Renal Failure: Our Experience. Renal failure, 23, 183-191. http://dx.doi.org/10.1081/JDI-100103490
[21]
Sever, M., Erek, E., Vanholder, R., Akoglu, E., Yavaz, M., Ergin, H., Tekce, M., Korular, D., Tulbek, M., Keven, K., et al. (2001) The Marmara Earthquake: Epidemiological Analysis of the Victims with Nephrological Problems. Kidney International, 60, 1114-1123. http://dx.doi.org/10.1046/j.1523-1755.2001.0600031114.x
[22]
Kantarci, G., Vanholder, R., Tuclular, S., Akin, H., Koc, M., Ozrner, C. and Akoglu, E. (2002) Acute Renal Failure Due to Crush Syndrome during Marmara Earthquake. American Journal of Kidney Diseases, 40, 682-689. http://dx.doi.org/10.1053/ajkd.2002.35673
[23]
Van Dam, R. (2006) Earthquake in Pakistan—The Renal Disaster Relief Task Force in Action. EDTNA-ERCA Journal, 32, 104-107. http://dx.doi.org/10.1111/j.1755-6686.2006.tb00461.x
[24]
Rosen, C., Adler, J., Rabban, J., Sethi, R., Arkoff, L., Blair, J. and Sheridan, R. (1999) Early Predictors of Myoglobinuria and Acute Renal Failure Following Electrical Injury. The Journal of Emergency Medicine, 17, 783-789. http://dx.doi.org/10.1016/S0736-4679(99)00084-0
[25]
Brumback, R., Feeback, D. and Leech, R. (1995) Rhabdomyolysis Following Electrical Injury. Seminars in Neurology, 15, 329-334 http://dx.doi.org/10.1055/s-2008-1041040
[26]
Grossman, R.A., Hamilton, R.W., Morse, B.M., Penn, A.S. and Goldberg, M. (1974) Nontraumatic Rhabdomyolysis and Acute Renal Failure. The New England Journal of Medicine, 291, 807-811.
[27]
Sweny, P. (1989) Pigment Nephropathy: Rhabdomyolysis and Hemolysis. In: Sweny, P., Farrington, K. and Morehead, J.F. Eds., The Kidney and Its Disorders, Chapter 22, Blackwell Scientific Publications, Oxford, 348-358.
[28]
Markowitz, H. and Wobing, G.H. (1977) Quantitative Methods for Estimating Myoglobin in Urine. Clinical Chemistry, 23, 1689-1693.
[29]
Haller, R.G. and Knochel, J.P. (1984) Skeletal Muscle Disease in Alcoholism. Medical Clinics of North America, 68, 91-103.
[30]
Song, S.K. and Rubin, E. (1972) Ethanol Produces Muscle Damage in Human Volunteers. Science, 175, 327-328. http://dx.doi.org/10.1126/science.175.4019.327
[31]
Knochel, J.P. (1992) Hypophosphatemia and Rhabdomyolysis. American Journal of Medicine, 92, 455-457. http://dx.doi.org/10.1016/0002-9343(92)90739-X
[32]
Kakulas, B. (1981) Experimental Myopathies. In: Walton, S.J., Ed., Disorders of Voluntary Muscle, Churchill Livingstone, New York, 393-400.
[33]
Sitprija, V., Gopalakrishnakone, P. and Martinez-Maldonado, M. (1998) Snake Bite, Rhabdomyolysis, and Renal Failure. American Journal of Kidney Diseases, 31, l-lii. http://dx.doi.org/10.1016/S0272-6386(14)70010-1
[34]
Chugh, K.S. (1989) Snake Bite Induced ARF in India. Kidney International, 35, 891-907.
[35]
Gold, B.S., Dart, R.C. and Barish, R.A. (2002) Bites of Venoumous Snakes. The New England Journal of Medicine, 347, 346-56. http://dx.doi.org/10.1056/NEJMra013477
[36]
Reid, H.A. (1961) Myoglobinuria and Sea Snake Bite Poisoning. British Medical Journal, 1, 1284-1289.
[37]
Naqvi, R., Naqvi, A., Akhtar, F. and Rizvi, A. (1998) ARF Developing after a Scorpion Sting. British Journal of Urology, 82, 295.
[38]
Mocan, H., Mocan, M.Z. and Kaynar, K. (1998) HUS Following a Scorpion Sting. Nephrology Dialysis Transplantation, 13, 2639-2640.
[39]
Valavi, E., Ansari, M.J.A. and Hoseini, S. (2011) ADAMTS-13 Deficiency Following Scorpion Sting. Saudi Journal of Kidney Diseases and Transplantation, 22, 792-795.
[40]
Dressler, W.E. and Appelqvist, T. (2006) Plasma/Blood Pharmacokinetics and Metabolism after Dermal Exposure to Para-Aminophenol or Para-Phenylenediamine. Food and Chemical Toxicology, 44, 371-379. http://dx.doi.org/10.1016/j.fct.2005.08.009
[41]
Stanley, L.A., Skare, J.A., Doyle, E., Powrie, R., D’Angelo, D., et al. (2005) Lack of Evidence for Metabolism of p-Phenylenediamine by Human Hepatic Cytochrome P450 Enzymes. Toxicology, 210, 147-157. http://dx.doi.org/10.1016/j.tox.2005.01.019
[42]
Meyer, A., Blomeke, B. and Fischer, K. (2009) Determination of p-Phenylenediamine and Its Metabolites MAPPD and DAPPD in Biological Samples Using HPLC-DAD and Amperometric Detection. Journal of Chromatography B, 877, 1627-1633. http://dx.doi.org/10.1016/j.jchromb.2009.04.008
[43]
Shalaby, S.A., Elmasry, M.K., Abd-Elrahman, A.E., Abd-Elkarim, M.A. and Abd-Elhaleem, Z.A. (2010) Clinical Profile of Acute Paraphenylenediamine Intoxication in Egypt. Toxicology and Industrial Health, 26, 81-87. http://dx.doi.org/10.1177/0748233709360200
[44]
Chrispal, A., Begum, A., Ramya, I. and Zachariah, A. (2010) Hair Dye Poisoning—An Emerging Problem in the Tropics: An Experience from a Tertiary Care Hospital in South India. Tropical Doctor, 40, 100-103. http://dx.doi.org/10.1258/td.2010.090367
[45]
Nagaraja, B.S., Spoorthy, S.S. and Mubarak, H. (2012) Hair Dye Poisoning: Case Report. International Journal of Clinical Cases and Investigations, 4, 43-48.
[46]
Fatihi, E.M., Ramdani, B., Benghanem, M.G., Hachim, K. and Zaid, D. (1997) Rhabdomyolysis and Acute Renal Failure Secondary to Toxic Material Abuse in Morocco. Saudi Journal of Kidney Diseases and Transplantation, 8, 131-133.
