A histological examination of the effects of Ferula elaeochytris extract on kidney and liver tissues in myoglobinuric acute renal failure.

Myoglobinuric acute renal failure (MARF) is a structural and functional disorder that occurs in the kidney following the release of muscle cell contents into the circulation. In this present study, possible protective and curative effects of Ferula elaeochytris extract against kidney and liver damage in experimentally induced MARF in a rat model were investigated. 3-4 Month-old, 200-250 g Sprague Dawley rats were divided into 8 equal groups with 7 rats per group. Group I was a no-intervention Control group. All groups except for the Group I were dehydrated for 16 hours. Following this dehydration, 50% v/v aqueous glycerol solution was injected into both hind leg muscles of the animals, at a dose of 8 ml/kg. The rats were given physiological saline (SF) once orally before the model was administered (Group II) and after the model was administered (Group V). Similarly, two different doses of Ferula elaeochytris root extract (40 mg/kg and 80 mg/kg) were dissolved in 2 ml of SF and administered orally before (Groups III and IV) and after (Group VI, VII) the model was created. Following the experimental period, kidney and liver tissues were removed from all groups, and fixed in 10% neutral formaldehyde solution for light microscopic examinations. Intracellular vacuolization, enlargement in the Bowman's space, widespread atrophy in the tubular structures, luminal enlargement, and desquamation were detected in the kidney tissue sections of all the experimental model groups. In the liver tissue sections, was detected hepatocyte degeneration, intracellular vacuolization, irregularity in cell membrane borders, and apoptotic bodies. These histopathological consequences of MARF were evaluated for all groups, and whereas a curative effect of Ferula elaeochytris could be seen, its protective effect was higher than its curative effect.

Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists.

Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.

Use of dexamethasone in idiopathic, acute pediatric rhabdomyolysis.

Current rhabdomyolysis treatment guidelines vary based on the etiology and diagnosis, yet many cases evade conclusive diagnosis. In these cases, treatment options remain largely limited to fluids and supportive therapy. We present two cases of acute rhabdomyolysis diagnosed in the emergency department: a 5-year-old boy with sudden onset bilateral flank pain, and a 13-year-old boy with 2-3 days of worsening pectoral and shoulder pain. Each patient had a prior similar episode requiring hospitalization in the past. The 5-year-old had no inciting trauma or trigger, medication use, or illness. The 13-year-old previously had an upper respiratory infection during the week prior and had been strenuously exercising at the time of onset. Genetic testing results were unknown for both patients during their hospitalizations, and insurance and other barriers led to delay. Later results for the first patient revealed a heterozygous deletion in intron 19 on the LPIN1 gene interpreted as a variant of unknown significance. During their hospitalizations, both children were started on intravenous (i.v.) fluids, and creatine kinase (CK) initially trended downward, but then began to rise or plateau. After reviewing the cases, prior literature, and anecdotal evidence of benefit from corticosteroid therapy in rhabdomyolysis with our consultant metabolic physicians, dexamethasone was initiated. In both patients, dexamethasone use correlated with relief of patient symptoms, significantly decreased CK value, and our ability to discharge these patients home quickly. Our cases, discussion, and literature review all lead to the consideration of the use of dexamethasone in conjunction with standard therapy for acute rhabdomyolysis.

Comparing the potential renal protective activity of desferrioxamine B and the novel chelator desferrioxamine B-N-(3-hydroxyadamant-1-yl)carboxamide in a cell model of myoglobinuria.

Accumulating Mb (myoglobin) in the kidney following severe burns promotes oxidative damage and inflammation, which leads to acute renal failure. The potential for haem-iron to induce oxidative damage has prompted testing of iron chelators [e.g. DFOB (desferrioxamine B)] as renal protective agents. We compared the ability of DFOB and a DFOB-derivative {DFOB-AdAOH [DFOB-N-(3-hydroxyadamant-1-yl)carboxamide]} to protect renal epithelial cells from Mb insult. Loading kidney-tubule epithelial cells with dihydrorhodamine-123 before exposure to 100 µM Mb increased rhodamine-123 fluorescence relative to controls (absence of Mb), indicating increased oxidative stress. Extracellular Mb elicited a reorganization of the transferrin receptor as assessed by monitoring labelled transferrin uptake with flow cytometry and inverted fluorescence microscopy. Mb stimulated HO-1 (haem oxygenase-1), TNFα (tumour necrosis factor α), and both ICAM (intercellular adhesion molecule) and VCAM (vascular cell adhesion molecule) gene expression and inhibited epithelial monolayer permeability. Pre-treatment with DFOB or DFOB-AdAOH decreased Mb-mediated rhodamine-123 fluorescence, HO-1, ICAM and TNFα gene expression and restored monolayer permeability. MCP-1 (monocyte chemotactic protein 1) secretion increased in cells exposed to Mb-insult and this was abrogated by DFOB or DFOB-AdAOH. Cells treated with DFOB or DFOB-AdAOH alone showed no change in permeability, MCP-1 secretion or HO-1, TNFα, ICAM or VCAM gene expression. Similarly to DFOB, incubation of DFOB-AdAOH with Mb plus H2O2 yielded nitroxide radicals as detected by EPR spectroscopy, indicating a potential antioxidant activity in addition to metal chelation; Fe(III)-loaded DFOB-AdAOH showed no nitroxide radical formation. Overall, the chelators inhibited Mb-induced oxidative stress and inflammation and improved epithelial cell function. DFOB-AdAOH showed similar activity to DFOB, indicating that this novel low-toxicity chelator may protect the kidney after severe burns.

Reversal of experimental myoglobinuric acute renal failure in rats by quercetin, a bioflavonoid.

The occurrence of acute renal failure (ARF) following rhabdomyolysis has been put at between 10 and 40% of cases, and accounts for between 3 and 15% of all cases of ARF. Reactive oxygen intermediates have been demonstrated to play an etiological role in myoglobinuric renal failure. This study was performed to explore the protective effect of quercetin, a bioflavonoid, in an experimental model of myoglobinuric ARF in rats. Four groups of rats were employed in this study: group 1 served as control, group 2 was given 50% glycerol (8 ml/kg, i.m.), group 3 was given glycerol + quercetin (2 mg/kg, i.p.), and group 4 was given glycerol + DMSO (the solvent for quercetin, 5 ml/kg, i.p.). Renal injury was assessed by measuring serum creatinine, blood urea nitrogen, creatinine and urea clearance. The oxidative stress was measured by renal malondialdehyde levels, reduced glutathione levels and by enzymatic activity of catalase, glutathione reductase, and superoxide dismutase. Glycerol administration resulted in a marked renal oxidative stress, significantly deranged the renal functions as well as renal cytoarchitecture. All these factors were significantly improved by quercetin treatment. Because of its radical-scavenging and iron-chelating properties, quercetin protected the kidney against the glycerol-induced oxidative stress and resultant renal dysfunction. Based on these results, this study confirms the role of oxidative stress and demonstrates the renoprotective potential of quercetin in this rhabdomyolysis-mimicking model.

Catechin, a natural antioxidant protects against rhabdomyolysis-induced myoglobinuric acute renal failure.

Rhabdomyolysis-induced myoglobinuric acute renal failure accounts for about 10-40% of all cases of acute renal failure (ARF). Reactive oxygen intermediates have been demonstrated to play an etiological role in myoglobinuric renal failure. This study was performed to explore the protective effect of catechin-a natural antioxidant in an experimental model of myoglobinuric ARF in rats. Four groups of rats were employed in this study, group 1 served as control, group 2 was given 50% glycerol (8 ml kg(-1), i.m.), group 3, glycerol plus catechin (40 mg kg(-1), p.o. for 4 days, twice a day) and group 4 was given only catechin (40 mg kg(-1), p.o.), respectively. Renal injury was assessed by measuring serum creatinine, blood urea nitrogen (BUN), creatinine, and urea clearance. The oxidative stress was measured by renal malondialdehyde (MDA) levels, reduced glutathione levels and by enzymatic activity of catalase, glutathione reductase (GR) and superoxide dismutase (SOD). Glycerol administration resulted in a marked renal oxidative stress, significantly deranged the renal functions as well as renal morphology. All these factors were significantly improved by catechin treatment. Catechin, due to its antioxidative activity, reduced the toxicity of myoglobin in the renal tissues, and thus exerted a renoprotective effect in this rhabdomyolysis mimicking model.

Reversal of experimental myoglobinuric acute renal failure with bioflavonoids from seeds of grape.

Rhabdomyolysis may account for about 10% of all cases of acute renal failure (ARF). This study was performed to explore the protective influence of proanthocyanidins from seeds of grape in an experimental model of myoglobinuric ARF. Rats were injected with 50% glycerol (8 mL/kg, im) followed immediately and daily in the next three days by ip proanthocyanidins (20 mg/kg) or saline. After 96 h rats were sacrificed and kidney morphology, kidney cortex peptidase activities, and malondialdehyde (MDA) content were determined. A moderate renal failure was produced by glycerol injection with blood urea of 31.8+/-11.0 vs. 7.68+/-0.24 m mol/L, and serum creatinine of 153. +/-38.2 vs. 39.6+/-9.0 micromol/L, in glycerol-induced ARF vs. control rats, respectively. Rats that received proanthocyanidins in addition to glycerol had significantly lower (p < 0.01) blood urea and serum creatinine levels compared to those receiving glycerol alone. These functional differences between the glycerol and glycerol plus proanthocianidins groups were also confirmed histologically. Kidney cortex dipeptidylpeptidase IV (DPP IV) activity was not significantly changed in glycerol-induced ARF, however, markedly increased after proanthocyanidins treatment. Kidney cortex malondialdehyde content was found significantly increased in glycerol-induced ARF over control level, and was markedly reduced by proanthocyanidin treatment. Taken together, these results provide strong evidence for the protective role of proanthocyanidins from seeds of grape in glycerol-induced ARF. The effect is probably due to the antioxidant activity of proanthocyanidins and to increased expression of kidney cortex DPP IV with effective degradation of TNF-alpha. This may provide therapeutic opportunities of preventing and/or treating myoglobinuric ARF in humans.

Effects of LTB4 receptor antagonist on myonephropathic metabolic syndrome: an experimental study.

The aims of this study were to determine the involvement of leukocytes in reperfusion injury following acute arterial occlusion and to evaluate the effect of the leukotriene B4 (LTB4), which is a chemical mediator of inflammation, receptor antagonist. We examined the usefulness of LTB4 receptor antagonist, ONO-4057, as a preventative drug for myonephropathic metabolic syndrome (MNMS). The experimental leg ischemic model was developed using Wistar strain rats. The rats were divided into 4 groups. In Group R3, the infra-renal abdominal aorta was clamped for 3 hrs and the right femoral muscle tissue was cut to block the development of a collateral artery. In Group R6, the infra-renal abdominal aorta was clamped for 6 hrs and the right femoral muscle tissue was cut. In Group C, the controls, there was no clamping of the abdominal aorta and the right femoral muscle tissue was cut. In Group M, the medicated group, rats were pretreated with an LTB4 receptor antagonist, ONO-4057, just before reperfusion. Blood serum interleukin-1 (IL-1), interleukin-8 (IL-8), creatine phosphokinase (CPK), and aldolase were measured and compared in each of those 4 groups. We also examined the intercellular adhesion molecule-1 (ICAM-1) expression in various organs (liver, heart and kidney) by immunohistochemistry. We found that IL-1 beta levels were low in all groups. CPK, aldolase and IL-8 levels after reperfusion in Group R6 significantly high compared with the levels in Group C (P < 0.03 about CPK, P < 0.05 about aldolase, and P < 0.05 about IL-8). The levels of CPK, aldolase, and IL-8 in Group M were significantly lower than those in Group R6 (P < 0.02 about CPK, P < 0.04 about aldolase, and P < 0.03 about IL-8). We determined immunohistochemically that the expression of ICAM-1 was positive on endothelial cells at the coronary artery and the small vein in Group R6 and that the expression of ICAM-1 was negative on endothelial cells in Group C. Those data suggested that ICAM-1 may play an important role in the progression of reperfusion injury, and the adhesion of neutrophilic leukocytes on endothelial cells may play a significant role in MNMS. LTB4 receptor antagonist may be useful for preventing reperfusion injury following acute aortic occlusion.

Rhabdomyolysis in association with Duchenne's muscular dystrophy.

PURPOSE: To present a case of rhabdomyolysis which developed in a child with a known history of Duchenne's muscular dystrophy, following an anesthetic which included sevoflurane. CLINICAL FEATURES: An 11 yr old boy with a known history of Duchenne's muscular dystrophy underwent anesthesia for strabismus repair. The anesthetic consisted of sevoflurane and nitrous oxide without the use of a muscle relaxant. His postoperative course was complicated by a complaint of heel pain and the development of myoglobinuria. He was treated with dantrolene sodium and discharged home after two days, without further complication. CONCLUSION: Sevoflurane anesthesia has not been shown previously to be associated with the development of acute rhabdomyolysis in a child with a history of Duchenne's muscular dystrophy. As with halothane and isoflurane, the continued use of sevoflurane in the presence of Duchenne's muscular dystrophy should be questioned.

Successful treatment of an episode of malignant hyperthermia using a large dose of dantrolene.

This clinical case report describes the use of extremely high doses of dantrolene in the management of an episode of malignant hyperthermia (MH). A 6-year-old, 25 kg girl underwent anesthetic induction with halothane for an elective inguinal herniorrhaphy. Tachydysrhythmias, laryngospasm, opisthotonos, rhabdomyolysis, and profound metabolic acidosis ensued as features of an MH crisis. Initial dantrolene administration did not alleviate the symptoms. Increasing doses of dantrolene eventually totaling 42 mg/kg, along with symptomatic supportive care, were administered successfully to treat the event. It is postulated that the severe muscle rigidity may have precluded the circulation of dantrolene to its site of action. The role of the Malignant Hyperthermia Association of the United States (MHAUS) Hotline as a 24-hour consultative service is noted.

Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. Mechanistic and therapeutic implications.

Mannitol (M) and deferoxamine (DFO) can each protect against myohemoglobinuric acute renal failure (MH-ARF). This study assessed M-DFO interactions during MH-ARF to help discern mechanisms of renal injury, and to define whether M + DFO exerts additive or synergistic antioxidant/cytoprotective effects. Rats subjected to the glycerol model of MH-ARF were treated with (a) M; (b) DFO; (c) M + DFO; or (d) no protective agents. Relative degrees of protection (24-h plasma urea/creatinine concentrations) were M + DFO greater than M greater than DFO greater than or equal to no therapy. To assess whether catalytic Fe is generated during MH-ARF, the bleomycin assay was applied to plasma/urine samples obtained 0-2 h post-glycerol injection. Although striking plasma and urinary increments were noted, excess renal hydroxyl radical (.OH) production was not apparent (gauged by the salicylate trap method). M increased catalytic Fe excretion (four times), whereas DFO eliminated its urinary (but not plasma) activity. To determine direct M/DFO effects on proximal tubular cell oxidant injury, isolated rat proximal tubular segments (PTS) were incubated with toxic dosages of FeSO4 or H2O2. Despite inducing cell injury (lactic dehydrogenase release), Fe caused no .OH production. DFO conferred dose-dependent cytoprotection, correlating with increased, not decreased, .OH generation. Although M scavenged this .OH excess, it had no additive or independent, protective effect. H2O2 cytotoxicity correlated with increased catalytic Fe (but not .OH) generation. The fact that DFO (but not .OH scavengers [M and dimethylthiourea]) blocked H2O2 toxicity implied Fe-dependent, .OH-independent cell killing. In conclusion, (a) striking catalytic Fe generation occurs during MH-ARF, but augmented intrarenal .OH production may not develop; (b) DFO can block Fe toxicity despite a prooxidant effect; (c) H2O2 PTS toxicity is Fe, but possibly not .OH, dependent; and (d) M does not mitigate oxidant PTS injury, either in the presence or absence of DFO, suggesting that its additive benefit with DFO in vivo occurs via a diuretic, not antioxidant effect.

Familial paroxysmal rhabdomyolysis: management of two cases of the non-exertional type.

Familial paroxysmal rhabdomyolysis with myoglobinuria is a rare and life-threatening disease of young children, of unknown aetiology. Attacks bear no relation to exercise, are usually triggered by intercurrent infections and are often severe. The authors describe two cases and suggest plans for the prevention and management of attacks. Fasting appears to be the crucial factor precipitating attacks, but is not associated with hypoglycaemia or with a defect in lactate production, ketogenesis or fatty acid mobilisation. The fatty acid-binding protein in a muscle biopsy from one case was normal.

The influence of mannitol on myoglobinuric acute renal failure: functional, biochemical, and morphological assessments.

This study was undertaken to explore the protective influence of mannitol against the glycerol model of myohemoglobinuric acute renal failure. Three hypotheses were tested: (1) mannitol confers cytoprotection by acutely blunting renal hypoperfusion, thereby improving tubular cell energetics; (2) as an hydroxyl radical (OH.) scavenger, mannitol mitigates Fe-driven lipid peroxidation and, hence, decreases tubular cell necrosis; and (3) mannitol prevents intrarenal heme pigment trapping, decreasing cast formation. Rats were injected with 50% glycerol (10 mL/kg im), followed immediately by an iv mannitol (1.25 mL/100 g over 1 h) or sham infusion. Mannitol induced a brisk diuresis (approximately 5.7 mL/2 h; approximately 35 mg of heme protein excreted), whereas glycerol controls were anuric. Mannitol did not significantly increase postglycerol RBF (2.8 mL/min), and it paradoxically worsened cellular energetics, halving cortical ATP concentrations at 1 h. However, this adverse effect on ATP was transient, correlating with active diuresis. Glycerol did not induce convincing in vivo lipid peroxidation (malondialdehyde; conjugated diene assay), and mannitol did not block Fe-driven in vitro lipid peroxidation of isolated brush border membrane vesicles. Na benzoate, an OH. scavenger, conferred no in vivo or in vitro protection. However, Na2SO4, not an OH. scavenger, reproduced the diuretic and in vivo protective effects of mannitol. Purified myoglobin infusion (35 mg) largely negated the beneficial action of mannitol. It was concluded that mannitol confers functional but not cytoprotection against the glycerol acute renal failure model, it acutely worsens renal bioenergetics, and its protective influence is probably due to a diuretic, not an antioxidant, effect.

Polymyositis with myoglobinuria in pregnancy: a report and review of the literature.

A pregnant patient developed fulminant polymyositis with myoglobinuria after terbutaline and magnesium sulfate tocolysis. Her response to prednisone was dramatic. Rapid relapse occurred after inadvertent postcesarean dose reduction. Our patient again responded to increased prednisone. She and her twin babies are well.

Rhabdomyolysis in thyroid storm.

This is the first reported case of thyroid storm complicated by rhabdomyolysis with acute reversible renal failure. The only possible causes for the rhabdomyolysis were inherent features of thyroid storm. Although hyperthyroid patients characteristically have normal or low serum levels of muscle enzymes, this case report demonstrates that rhabdomyolysis with elevated serum levels of muscle enzymes can occur with hyperthyroidism. An appreciation of the potential for rhabdomyolysis in hyperthyroidism should facilitate prompt initiation of aggressive therapy for myoglobinuria and thereby limit the severity of acute renal failure in these already very sick patients.

Hypokalemic rhabdomyolysis with myoglobinuria due to licorice ingestion and diuretic treatment.

A 54-year-old man was admitted to hospital with acute rhabdomyolysis and myoglobinuria due to hypokalemia. The hypokalemia was due to chronic licorice ingestion and diuretic treatment. The myoglobinemia led to a glomerulopathy and tubulopathy. There was, however, no clinical evidence of acute renal failure (ARF). We propose that the volume expansion caused by the steroid-like actions of licorice might have prevented the development of an ARF.

The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria.

Twenty patients who had evidence of myoglobinuria were treated with intravenous infusions of mannitol and sodium bicarbonate. Nine patients (group 1) responded with higher urine output, and continued infusion improved renal function; none required dialysis and all survived. Eleven patients (group 2) did not respond to the infusion, and required an average of 5.3 (range, 0 to 11) dialyses; one patient died. There was no significant difference in initial BUN level, creatinine level, BUN/creatinine ratio, or fractional sodium excretion level between the two groups. However, group 2 patients had a significantly higher creatine phosphokinase (CPK) level, serum phosphate level, and hematocrit reading initially than did group 1, indicative of more severe muscle injury and hemoconcentration. These results demonstrate that some patients with myoglobinuria will respond to infusion of mannitol and sodium bicarbonate. This treatment may be effective in altering the clinical course of myoglobinuric acute renal failure.