Rhabdomyolysis NSG 530

Instructions

Here is the post for week 10’s reply.

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Injuries associated with extreme exercise have been climbing at an increasing rate in the United States (Lecina et al., 2021). In order to understand this phenomenon more thoroughly researchers have begun examining muscle damage biomarkers such as creatine kinase, lactate dehydrogenase, and magnesium (Rojas-Valverde et al., 2019). In addition to muscle damage, constant mechanical trauma to the kidney can result from these exercises (Rojas-Valverde et al., 2019).

This form of damage to the kidneys is typically measured by cystatin C (sCyst-C), serum creatinine (sCr), estimation of glomerular filtration rate (sGFR), creatinine clearance and blood ureic nitrogen (sBUN) and (Rojas-Valverde et al., 2019). Rhabdomyolysis is known to be caused by the rapid breakdown of skeletal muscle (Morris et al., 2019). Rhabdomyolysis can present as myalgia, weakness, and myoglobinuria (Morris et al., 2019).

The best test measuring for Rhabdomyolysis is testing for a CK level greater than 975 IU/L (Morris et al., 2019). The patient has a CK of 23,000 U/L indicative of rhabdomyolysis. It seems that this patient is suffering from the rarer rhabdomyolysis of exertional rhabdomyolysis caused by intense and vigorous exercise (Morris et al., 2019). Imaging such as an MRI can be done to assess for edema of the muscle, although this is not indicative of specifically rhabdomyolysis it will only help to support the diagnosis (Morris et al., 2019).

Damage to the kidneys from rhabdomyolysis can be caused by myoglobin being released into the bloodstream following sarcolemma rupture, vasoconstriction, hemoprotein, and myoglobin filtration through the glomeruli in the tubular system of the kidneys affecting perfusion, and ischemia (Lecina et al., 2021). In order to combat the issues with perfusion causing possible acute renal failure in patients with rhabdomyolysis intense intravenous fluids should be administered (Morris et al., 2019). The patient in this case study is experiencing elevated CK levels and edema of the muscle which is sufficient for diagnosing rhabdomyolysis.

References

Lecina, M., López, I., Castellar, C., & Pradas, F. (2021). Extreme Ultra-Trail Race Induces Muscular Damage, Risk for Acute Kidney Injury and Hyponatremia: A Case Report. International journal of environmental research and public health, 18(21), 11323. https://doi.org/10.3390/ijerph182111323

Morris, R. W., M.D., & Jennings, M. C., D.O. (2019). Exertional rhabdomyolysis. Applied Radiology, 48(4), 36-37.https://wilkes.idm.oclc.org/login?url=https://www.proquest.com/ scholarly-journals/exertional-rhabdomyolysis/docview/2283948863/se-2

Rojas-Valverde, D., Sánchez-Ureña, B., Pino-Ortega, J., Gómez-Carmona, C., Gutiérrez-Vargas, R., Timón, R., & Olcina, G. (2019). External Workload Indicators of Muscle and Kidney Mechanical Injury in Endurance Trail Running. International journal of environmental research and public health, 16(20), 3909. https://doi.org/10.3390/ijerph16203909

Solution

Response

Hi,
I appreciate the information you provided in your initial discussion regarding the pathophysiology of acute renal failure in rhabdomyolysis. I agree with your perception that rhabdomyolysis is caused by damage to the skeletal muscles, which then leads to serious health complications. You provided good points that are clear and easy to understand, therefore, this reply is to either support or add new information.

According to Kwiatkowska et al. (2020), Rhabdomyolysis (RM) is commonly caused by a crush syndrome or extensive muscle damage that happens after direct injury or trauma. Rhabdomyolysis (RM) may occur due to extreme physical activity, which might have been the case in the case study. The main mechanism leading to kidney damage in patients diagnosed with Rhabdomyolysis is the massive leakage of myoglobin into the circulation.

Normally, Myoglobinuria is noticeable when urine myoglobin excretion exceeds 100 to 300 mg/dL. When this incident happens, an accumulation of iron occurs in the proximal tubules associated with intratubular obstruction and proximal tubular cell injury (Esposito et al., 2018). Consequently, intracellular fluid is sequestrated into the extracellular spaces leading to reduced intravascular volume, which activates the renin-angiotensin-aldosterone system (RAAS) and in turn leads to reduced blood flow (Kwiatkowska et al., 2020).

High concentration of myoglobin causes cytotoxic and damaging effects on the nephrons. Another mechanism associated with acute renal failure in patients with rhabdomyolysis is lipid membrane components peroxidation that occurs after reacting with a ferryl form of myoglobin (redox-cycling) (Kwiatkowska et al., 2020). This situation leads to metabolic acidosis, resulting in aciduria, which may make worse tubular damage.

Just to add on top of what the student provided, the preferred way of preventing acute kidney injury in patients with rhabdomyolysis includes the use of saline solutions to restore intravascular volume and to enhance the treatment of the underlying cause of rhabdomyolysis (Esposito et al., 2018). There are other treatment strategies such as renal replacement therapy and the use of diuretics. In addition, there are new strategies of treatment such as iron chelators and antioxidants, anti-inflammatory treatment, and others (Kwiatkowska et al., 2020). The doctor should determine the most appropriate form of treatment based on several factors.

References

Esposito, P., Estienne, L., Serpieri, N., Ronchi, D., Comi, G. P., Moggio, M., & Rampino, T. (2018). Rhabdomyolysis-associated acute kidney injury. American Journal of Kidney Diseases, 71(6), A12-A14. https://doi.org/10.1053/j.ajkd.2018.03.009
Kwiatkowska, M., Chomicka, I., & Malyszko, J. (2020). Rhabdomyolysis–induced acute kidney injury–an underestimated problem. Wiad. Lek, 73(11), 2543-2548. https://doi.org/10.36740/WLek202011137

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