Rhabdomyolysis

Is elevated serum CK level an indication for renal replacement therapy?

Presented by Ri 黃崧溪

Pathophysiology

Physical injuryHypoxia

Electrolyte disturbance

Skeletal muscle cell destruction

Metabolic

InfectionToxin and drugs

Intracellular Extracellular

Na, Cl, Ca, Water

K, P, purines, myoglobulin, creatinine, creatine kinase, lactic and other organic acid,

American Family Physician (2002) 65:907-912

Clinical complications

• Early complications: - hyperkalemia, hypocalcemia, hyperphosphatemia, hyperu

ricemia, acidosis - cardiac arrhythmia - hypovolemia• Late complications: - Acute renal failure - DIC - Compartment syndrome - Hypercalcemia

American Family Physician (2002) 65:907-912

ARF in rhabdomyolysis

• Incidence: 8-20%• Associated with higher mortality and morbidity

compared to those patients who have rhabdomyolysis without ARF

The journal of trauma (2004) 56:1191-1196

How rhabdomyolysis causes acute renal dysfunction?

1. Tubular obstruction

2. Lipid peroxidation

3. Renal vasoconstriction

Intensive care medicine (2001) 27:803-811

Myoglobin

• MW: 16700

• functions as an oxygen-storage unit, providing oxygen to the working muscles

Myoglobin in rhabdomyolysis

• Myoglobin had faster elimination kinetics than creatine kinase (p < .01)

• Metabolism of myoglobin: poorly understood, and in normal conditions, only small amounts are detected in serum and urine.

• Major route for myoglobin elimination: the reticuloendothelial system and renal tubuli

• The average times to reach the 50% level of initial values:12 hrs for myoglobin vs 42 hrs for creatine kinase.

Critical care medicine(2002) 30:2212-2215

Myoglobin in rhabdomyolysis

• Elimination of myoglobin is not influenced by renal function and urinary clearance of myoglobin is low, suggesting a major role of extrarenal removal

• Serum myoglobin > 500nmol/L needs hemodialysis• P’t with serum myoglobin 35-414nmol/L tolerate wit

h alkaline diuresis• Better correlate with clinical outcome than CK

Critical care medicine(2002) 30:2212-2215

Critical care medicine(2002) 30:2212-2215

Creatine kinase

• Creatine kinase isoenzymes are dimers of M and B chains, 3 forms: MM, MB and BB

• M and B subunit ranging from 39 to 42kD• These isoenzymes reside in the cytosol and

facilitate the egress of high energy phosphates into and out of mitochondria

• A large percentage of the CK that is released is degraded locally or in lymph

CK and rhabdomyolysis

The journal of trauma (2004) 56:1191-1196

CK and rhabdomyolysis

- Elevated serum CK is identified as a risk factor

- Cut point proposed: 500, 5000, 16000, 75000 U/L

- “loose correlation”

…American family physician(2002); 65: 907-912

Principle of Treatment

• Volume expansion• Alkalinisation• Mannitol• Antioxidants?• Early intervention was associated with bette

r prognosis

Intensive care medicine (2001) 27:803-811The journal of trauma (2004) 56:1191-1196

Indication of renal replacement therapy in ARF

• S/S of uremic syndrome

• Refractory hypervolemia, hyperkalemia or acidosis

• BUN>100mg/dL

Harrison’s Principles of internal medicine 16th ed.

When to start renal replacement therapy in patient with

rhabdomyolysis?• When conventional methods are ineffective

on correcting hyperkalemia

• When iatragenic fluid expansion has occurred but the patient remain oliguric

• For the prevention of ARF?

Renal failure (2001) 23:183-191

The justification of prophylactic dialysis treatment

• Dialytic treatment is the pathogenetic therapy by myoglobin removal

Renal failure (2001); 23: 183-191

• CVVH improves myoglobin clearance 10% per day in pig model

• Clinical advantage has not yet been conveyed

Intensive care medicine (2001) 27:803-811

Conclusion• Is elevated serum CK level an indication for renal replacement t

herapy in rhabdomyolysis? No, because: For treatment: 1. CK itself is not harmful2. If no other indicationFor prevention of ARF:1. Efficacy of preventive role of dialytic therapy is not established2. CK eliminates slower than myoglobin3. No definite level of CK predict renal failure

In our case-

15-year-old boy, generally well before Mon: Alternating split squat jump at school no significant symptoms were noted then. C.C.: hematuria bilateral leg pain and lower back

pain since Tue

U/A: brown and cloudy, OB 4+, RBC 11-20; Blood: GOT 1326, GPT 153, BUN 7.6, AC sugar 105, Cr 0.8, amylase 65.

In our case-

• 2.5% G/S + Jusomin + Mannitol

• CVVH for “prevention of ARF”

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0930904 (0914) 235200 0930904 (2024) 190000 0930905 (0824) 2110080930905 (2025) 1552320930906 (0914) 101375 0930906 (1953) 50125 0930907 (1011) 309000930907 (2041) 22300 0930908 (1006) 20900 0930909 (1154) 3822

In our case-

• Is there some underlying precipitating factors for this young boy to develop rhabdomyolysis?

• The individual is physically untrained• Exertion in extremely hot, humid conditions • Normal heat loss through sweating is impaired,

( anti-cholinergic medications or heavy football equipment)

• Sickle cell trait who exercises at high altitude

THANKS FOR YOUR ATTNESION!!