Rabdomiólisis y daño renal agudo asociado a infección por Clostridium difficile, reporte de caso / Rhabdomyolysis and acute kidney injury associated with Clostridium difficile infection, case report

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Severe myoglobinuric acute kidney injury in a kidney recipient: rapid recovery after hemodialysis with the super high-flux membrane Theralite®â€©.

Myoglobinuric acute kidney injury (AKI) is a severe condition requiring early therapeutic strategies. Early recognition and treatment are crucial to reduce morbidity and mortality rate. Here, we report a kidney recipient with severe rhabdomyolysis and AKI secondary to parvovirus B19 infection. Initiation of hemodialysis with the super high-flux filter Theralite® (Gambro, cut-off 45 kDa, 2.1 m2) resulted in the clearance of myoglobin from 61 to 71% after 3 hours. Elimination rates of IL-6 and ß2-microglobulin were ~ 30 - 64% and 55 - 71% after 3 hours, respectively. Renal graft function rapidly recovered. The place of this effective but expensive procedure still needs to be defined and validated in high-risk patients.
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Case Report: Red Urine After Day Care Strabismus Surgery.

In the absence of surgery on the urinary tract, the emission of red urine after anesthesia should be considered as a diagnostic emergency because it can be a sign of hematuria, hemoglobinuria, blood transfusion reaction, significant myoglobinuria, or porphyria.This case describes the management of a 12-year-old boy who presented red urine at the day care unit after strabismus surgery.

Myoglobin removal using high-volume high-flux hemofiltration in patients with oliguric acute kidney injury.

BACKGROUND: Rhabdomyolysis can cause acute kidney injury (AKI). It remains controversial whether or not myoglobin can be removed from the circulation with extracorporeal therapy and decrease the incidence of AKI. Therefore, we examined myoglobin removal in a series of 11 patients with oliguric AKI treated with high-volume hemofiltration. METHODS: Patients received prefilter hemofiltration using a polysulphone filter with a molecular size cutoff of 65 kDa and a surface area of 1.7 m(2). Sieving coefficients and myoglobin clearances were calculated at 6, 12, and 24 h after the start of hemofiltration. RESULTS: The mean sieving coefficient was 0.158, and the mean myoglobin clearance was 8.7 ml/min. CONCLUSION: Despite the use of high-volume hemofiltration, the removal of myoglobin was negligible. In patients with normal renal function, the anticipated amount of extracorporeal removal would not significantly impact renal exposure to myoglobin.

Border-crossers' nephropathy: the risk of coming to America.

Immigrants attempting to cross the border often wander for days without food or water, subsequently developing acute kidney injury (AKI) secondary to rhabdomyolysis. In this article, we describe our experience with myoglobinuric AKI in these border crossers. Records from all patients in the custody of the border patrol from 1 June 2010 to 30 June 2011, who had AKI defined by the Acute Kidney Injury Network (AKIN) criteria and a CK > 1000 IU/L, were reviewed. The age, gender, temperature, days in the desert, initial serum creatinine, CK on presentation, need for dialysis, length of hospital stay, and serum creatinine at discharge were recorded and analyzed. Forty-two patients developed myoglobinuric AKI with a mean age of 32.5 years. Among them, 38 were males and four females. There was a mean of 4.2 days in the desert. Seven had stage 1 AKI, 10 stage 2, and 25 stage 3. 5 patients required hemodialysis. Only one patient had a temperature >100.6ºF on arrival. CKs ranged between 1101 and 447,966 IU/L. Mean length of stay was 4 days. Two patients were discharged on hemodialysis and eight were discharged with serum creatinine levels of  >1.3 mg/dL. This is the largest series of myoglobinuric AKI reported in border crossers. The kidney injury is presumably due to the excessive heat combined with volume depletion. We have coined the term "border crossers' nephropathy" for this disorder. This is a serious problem that has both political and economic consequences on both sides of the border.

Rhabdomyolysis in a recreational swimmer.

Rhabdomyolysis is a clinical and biochemical syndrome resulting from skeletal muscle injury, which may ultimately lead to acute renal failure (ARF) and death. Exertional rhabdomyolysis refers to skeletal muscle injury that is usually induced by strenuous eccentric exercises in a hot and humid environment. It is usually seen in marathoners and military personnel. We present the case of a 32-year-old Malaysian man who had rhabdomyolysis and myoglobinuria without ARF after two episodes of unaccustomed swimming. He was treated conservatively, and recovered uneventfully. A brief discussion on the pathophysiology of rhabdomyolysis, the principles of management and recuperation is included.

High cut-off renal replacement therapy for removal of myoglobin in severe rhabdomyolysis and acute kidney injury: a case series.

BACKGROUND/AIM: Rhabdomyolysis is associated with the release of myoglobin into the circulation, promoting acute kidney injury (AKI). In severe rhabdomyolysis, dialysis-dependent AKI doubles mortality. Standard blood purification techniques have limited efficacy in removing myoglobin. We describe high cut-off (HCO) renal replacement therapy (RRT) as a novel approach for extracorporeal elimination of myoglobin in rhabdomyolysis-associated AKI. METHODS: With an in vivo molecular cut-off at 45 kDa, HCO filters are effective in removing myoglobin (17.8 kDa). Clearances across standard and HCO filters using continuous or intermittent RRT are reviewed in a case series of 11 patients with severe rhabdomyolysis and dialysis-dependent AKI. RESULTS: Median myoglobin clearance across standard high-flux filters was 3.3 (interquartile range 2.3-3.9) ml/min for sustained low-efficiency daily dialysis (SLEDD) batch hemodialysis (HD) and 3.7 (2.9-6.7) ml/min for conventional HD. Respective clearances using HCO filters (membrane surface area: 1.1 m(2)) were 21.7 (20.3-26.1) ml/min (SLEDD) and 44.2 (41.3-47.0) ml/min (HD). Corrected for filter size, up to 20-fold higher clearances were obtained using HCO filters, resulting in profound and sustained reduction of plasma myoglobin concentration. CONCLUSIONS: As a novel approach, HCO RRT allows for rapid and effective removal of myoglobin from the circulation. In light of the pathogenic role in AKI, reducing exposure of the kidney to myoglobin may improve renal recovery and patient outcome. Our data pave the way for prospective trials, addressing this issue.

Rhabdomyolysis: a review of the literature.

Rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes; the classic findings of muscular aches, weakness and tea-coloured urine are non-specific and may not always be present. The diagnosis therefore rests upon the presence of a high level of suspicion of any abnormal laboratory values in the mind of the treating physician. An elevated plasma creatine kinase (CK) level is the most sensitive laboratory finding pertaining to muscle injury; whereas hyperkalaemia, acute renal failure and compartment syndrome represent the major life-threatening complications. The management of the condition includes prompt and aggressive fluid resuscitation, elimination of the causative agents and treatment and prevention of any complications that may ensue. The objective of this review is to describe the aetiological spectrum and pathophysiology of rhabdomyolysis, the clinical and biological consequences of this syndrome and to provide an appraisal of the current data available in order to facilitate the prevention, early diagnosis and prompt management of this condition.

Rhabdomyolysis after transnasal repair of anterior basal encephalocele.

BACKGROUND: Postoperative Rhabdomyolysis (RM) is rare after neurosurgical procedures. Furthermore, it has not been observed after transnasal approaches. The authors report a case of idiopathic RM occurring after transnasal resection of a sincipital encephalocele. CASE DESCRIPTION: A 32-year-old woman underwent a transnasal resection of a sincipital encephalocele after 6 years of intermittent clear nasal drainage. Postoperatively, she experienced severe back pain, peripheral neuropathy, associated with a markedly elevated creatinine kinase, and severe RM. The patient was treated with hydration and forced urine alkalization and treated symptomatically for her pain and neuropathy. She ultimately made a full recovery without complication. CONCLUSION: Rhabdomyolysis is a rare but known complication of neurosurgical procedures. We report the first known case report of RM after a transnasal procedure. Furthermore, a review of documented postneurosurgical cases of RM is presented and reveals that the causes and risk factors for this complication after neurosurgery are similar to those in other surgical subspecialties.

Influenza A-associated rhabdomyolysis with acute renal failure.

Rhabdomyolysis induced acute renal failure as a rare complication of influenza A infection has been mainly described in adults. Consideration of this potentially life-threatening complication in pediatric patients presenting with influenza is important as clinical symptoms may be unspecific and early diagnosis leading to prompt treatment is essential to decrease associated morbidity and mortality. We report a 9 year old girl who developed severe rhabdomyolysis with myoglobinuric renal failure associated with influenza A virus infection. Receiving supportive therapy including intensive care management the patient recovered renal function completely.

Trastornos del metabolismo energeético del músculo: Manifestaciones clínicas, diagnóstico y tratamiento de las miopatías que cursan con intolerancia al ejercicio / Metabolic myopathyies: clinical Manifestations, diagnosis and treatment of myopathies associated with exercise intolerance

Las miopatías en general y la enfermedad de McArdle en particular tienen una gran heterogeneidad clínica, de tal forma que aunque en todos los pacientes con la misma miopatía falla el mismo gen, las manifestaciones clínicas de la enfermedad son muy variables de unos pacientes a otros. El síntoma común en casi todos los enfermos es la fatiga generalizada en mayor o menor grado, así como los dolores musculares después del ejercicio de cierta intensidad, los músculos más afectados son los de las extremidades superiores. Esta intolerancia al esfuerzo se manifiesta con los siguientes síntomas y signos: fatiga y debilidad muscular, que suelen ir acompañados de mialgias y calambres musculares, e incluso de un mayor riesgo de padecer daño muscular (rabdomiolisis) con la consecuente mioglobinuria. Entre los métodos diagnósticos que pueden ayudara identificar el trastorno muscular podemos enumerar: La historia clínica, el electromiograma, test de fatiga muscular, test de esfuerzo con análisis de gases, test de esfuerzo con análisis de lactato y amonio, la bioquímica sanguínea, la resonancia magnética nuclear, la biopsia muscular, test defunción muscular, test de provocación. Todos ellos juntos son necesarios, dada la gran cantidad de enfermedades musculares existentes, así como la heterogeneidad de cada una de ellas, manifestándose con síntomas muy diferentes en cada enfermo. La terapia génica puede ser una solución para estos pacientes y aunque ya existe algunos trabajos a este respecto todavía pasaran años para poder aplicarla en humanos, así que mientras tanto debemos mantenerla calidad de vida de estos pacientes evitando la pérdida progresiva de su masa muscular relacionada directamente con enfermedades asociadas al sedentarismo y para ello contamos con el ejercicio como arma terapéutica que bien dosificada y con un seguimiento adecuado e individualizado puede brindar a este enfermo neuromuscular una mejora de su salud general (AU)

Myopathies in general and McArdle disease in particular have heterogeneous phenotype manifestations,i.e. the same genetic defect can be associated with varying clinical manifestations. The most common symptom is easy fatigueduring exercise and myalgia (affecting mostly upper limb muscles). Such exercise intolerance is usually associated with muscle weakness and cramps, and an increased risk of rhabdomyolysis and subsequent myoglobinuria. Among the different diagnostic tools are the following: clinical history, EMG, exercise test including lactate and ammonia measurements in blood, blood biochemistry, NMR, muscle biopsy and genetic analysis. Gene therapy might be useful in the future. In the meantime, individualized, supervised exercise training appears as the only tool to prevent further loss in patients’ muscle mass (AU)

Rhabdomyolysis.

Rhabdomyolysis is a syndrome involving the breakdown of skeletal muscle causing myoglobin and other intracellular proteins and electrolytes to leak into the circulation. The development of rhabdomyolysis is associated with a wide variety of diseases, injuries, medications and toxins. While the exact mechanisms responsible for all the causes are not fully understood, it is clear that muscle damage can occur from direct injury or by metabolic inequalities between energy consumption and energy production. Rhabdomyolysis is diagnosed by elevations in serum creatine phosphokinase (CPK), and while there is no established serum level cut-off, many clinicians use five times the upper limit of normal ( approximately 1000 U/l). Rhabdomyolysis can be complicated by acute renal failure (occurring in 4%-33% of patients), compartment syndrome, cardiac dysrhythmias via electrolyte abnormalities, and disseminated intravascular coagulopathy. The mainstay of treatment is hospitalisation with aggressive intravenous fluid (IVF) resuscitation with the correction/prevention of electrolyte abnormalities. There are additional adjunctive therapies to IVF, such as alkalinisation of the urine with sodium bicarbonate, diuretic therapy or combinations of both; however the lack of large randomised control studies concerning the benefits of these treatments makes it difficult to make strong recommendations for or against their use in the treatment of rhabdomyolysis. Regardless of these controversies, the overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common. Irrespective of the cause of rhabdomyolysis the mortality rate may still be as high as 8%. This is a comprehensive review of the pathophysiology, diagnosis, complications and treatment options for rhabdomyolysis.

High body mass index in muscular patients and flank position are risk factors for rhabdomyolysis: case report after laparoscopic live-donor nephrectomy.

BACKGROUND AND PURPOSE: Rhabdomyolysis is well known after traumatic crush injuries or ischemia involving muscles. Postoperatively, it most likely is secondary to surgical positioning and patient muscle mass. We report a case after laparoscopic live-donor nephrectomy. CASE REPORT: A muscular 35-year-old man underwent elective left laparoscopic live-donor nephrectomy in a 70 degrees flank position with four ports. He was in the right-side lying position with hip flexion (flank position) for approximately 4 hours. A kidney bridge had been placed between the iliac crest and the rib cage. Postoperatively, the patient had light-pinkish urine and low urine output. There was marked induration of the buttocks and significant pedal and scrotal edema. With judicious use of alkalinization and diuretics, the patient did not require dialysis, and renal function returned to base level by postoperative day 20. The recipient of the kidney had a normal postoperative course. CONCLUSION: Rhabdomyolysis is a syndrome of muscle necrosis and release of intracellular components into the circulation. Acute renal failure secondary to myoglobinuria is a common complication. We currently use little flexion of the table during donor nephrectomy and bring the table to a neutral position immediately after kidney retrieval. Postoperatively, one needs a high index of suspicion for rhabdomyolysis to avoid or at least promptly recognize this rare but potentially serious condition after any operation lasting >or=4 hours.

Lightning injuries and acute renal failure: a review.

Lightning strikes cause multimodal injuries in victims, and although the number of deaths due to lightning is reportedly in the area of 1,000 deaths per year, they cause significant morbidity in many others. A major complication of a lightning strike is acute renal failure (ARF). The true incidence of ARF due to lightning injuries worldwide is difficult to ascertain because of significant underreporting, due in large measure to cultural and sociodemographic factors. Its incidence is reportedly rare in some literature and significant in others. However, lightning's potential to cause ARF due to myoglobinuria has been noted by many authors. Prompt treatment of myoglobinuric patients prevents the development of ARF. ARF due to direct organ damage by lightning is virtually unheard of. In this article, the current mechanisms of lightning injuries leading to muscle damage, myoglobinuria, and subsequent ARF are discussed, as well as signs and symptoms, laboratory investigations, and patient management.

Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report.

OBJECTIVE: To test the ability of a novel super high-flux (SHF) membrane with a larger pore size to clear myoglobin from serum. SETTING: The intensive care unit of a university teaching hospital. SUBJECT: A patient with serotonin syndrome complicated by severe rhabodomyolysis and oliguric acute renal failure. METHOD: Initially continuous veno-venous hemofiltration was performed at 2 l/hour ultrafiltration (UF) with a standard polysulphone 1.4 m2 membrane (cutoff point, 20 kDa), followed by continuous veno-venous hemofiltration with a SHF membrane (cutoff point, 100 kDa) at 2 l/hour UF, then at 3 l/hour UF and then at 4 l/hour UF, in an attempt to clear myoglobin. RESULTS: The myoglobin concentration in the ultrafiltrate at 2 l/hour exchange was at least five times greater with the SHF membrane than with the conventional membrane (>100,000 microg/l versus 23,003 microg/l). The sieving coefficients with the SHF membrane at 3 l/hour UF and 4 l/hour UF were 72.2% and 68.8%, respectively. The amount of myoglobin removed with the conventional membrane was 1.1 g/day compared with 4.4-5.1 g/day for the SHF membrane. The SHF membrane achieved a clearance of up to 56.4 l/day, and achieved a reduction in serum myoglobin concentration from >100,000 microg/l to 16,542 microg/l in 48 hours. CONCLUSIONS: SHF hemofiltration achieved a much greater clearance of myoglobin than conventional hemofiltration, and it may provide a potential modality for the treatment of myoglobinuric acute renal failure.