Rhabdomyolysis and Acute Kidney Injury Requiring Dialysis
Background : Acute kidney injury (AKI) with myoglobinuria is the most serious complication of rhabdomyolysis, and it may be life threatening. Acute kidney injury as a complication of rhabdomyolysis represents about 7 to 10% of all cases of acute kidney injury in the United State.
Case Ilustration : A 42-year-old man presented with altered mental status after being found strangulated 3 hours before admission. Five day prior to admission he had ingested detergent with the intention of suicide. He had a history of paranoid schizophrenia that had been medicated with risperidone for 2 years. He denied history of trauma or injury. History of hypertension. On initial examination, he was unresponsive with a glasgow coma score of 3, attention and orientation was not adequate, hemodynamic were stable. Vulnus Excoriatum and circular hematom were on cervical area . In the patient’s initial laboratory, evaluation showed leukocyte 19690/ul, low potassium 2,8 mEq/L, high ALT and AST, ureum 13 mg/dl, creatinine was 1,639 mg/dl and creatinine increased 6,8 mg/dL on 3th and 9,7 mg/dL on 4th day, high serum uric acid and low serum calsium. Blood gas analysis showed bicarbonate 20,5. HCV serology was positive. Cervical x rays showed swelling on retrofaring soft tissue. Chest x ray showed cardiomegaly, infilltrate on right lung and kidney ultrasonography showed no abnormality. Diagnosed were acute kidney injury, rhabdomyolysis, schizophrenia paranoid, pneumonia, hypertension, vulnus ekscoriasis regio collie caused by strangulated, hipocalcemia and reactif leukositosis. He was started on intravenous hydration with KN2 at 1000 mL daily. He also got haloperidol 5 mg daily, risperidone 2 mg daily, 2 times daily, KSR 600 mg 3 times daily and antibiotic ceftriaxone 2 gram daily and Ramipril. The intra venous fluid rate was increased to 1500 mL daily, he remained oliguria with persistent hyperkalemia. He was started intermittent conventional hemodialysis on 4 of the hospitalization. He was dialyzed for 2 sessions. Urine output started to improve on Day 6 when his 24 hours’ urine output was 1000 mL. His last dialysis was on day 6th of hospitalization after which creatinine and CK continued to improve without dialysis. After 24 days of hospitalization he was discharged, his creatinine was 1.6 mg/dL and CK was 299 IU/L.
Discussion : The earlier patients receive supportive therapy. Initiate volume repletion with normal saline promptly, target urine output of approximately 3 ml per kilogram of body weight per hour. In patients who develop oliguria, administration of intravenous fluids is limited due volume expansion and pulmonary edema. In these cases, RRT is indicated. Intermittent hemodialysis, has the added benefit of correcting volume overload and pulmonary edema. Bicarbonates to induce urinary alkalinisation.
Conclusion : Acute kidney injury is the most serious complication of rhabdomyolysis. Fluid overload and imbalance electrolyte need renal replacement therapy.
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