Acute renal failure and rhabdomyolysis

Abstract

A previously healthy 20-year-old male was admitted to the University of Tokyo Hospital because of weakness in his legs and transient syncope during a marathon that day. The ambient temperature was 21.8°C, and the relative humidity was 60%. The patient took part in the race despite having symptoms of a common cold; he had taken no medication. Complaining of weakness in his legs, he collapsed after having run approximately 7 km. At that time, he was reportedly disoriented and slightly confused. Profuse sweating was observed. Physical examination at the hospital showed that he was alert and oriented but had mild amnesia. He complained of diarrhea and severe thirst. Body temperature was 39.1°C; blood pressure, 106/60 mm Hg; pulse, 130 to 150/mm; and respiratory rate, 54/mm. Examination of the eyes, heart, lungs, abdomen, and extremities was unremarkable. Patellar and Achilles tendon reflexes were suppressed slightly. An electrocardiogram showed sinus tachycardia and was otherwise normal. The urine was dark brown and benzidine positive. The urine osmolality was 222 mOsm/kg H20; pH was 6.0. Proteinuria, 1+ glucosuria, and microhematuria were present. The urine sodium concentration was 56 mEq/liter, and the urine creatinine concentration was 19.5 mg/dl. Serum electrolyte evaluation showed: sodium, 141 mEq/liter; potassium, 3.0 mEq/liter; chloride, 101 mEq/liter; calcium, 11.0 mg/dl. Other laboratory studies revealed: serum total protein, 9.0 g/dl; glucose, 80 mg/dl; creatinine, 2.7 mg/dl; and BUN, 20 mg/dl. Glutamic oxalacetic transaminase (GOT) and lactic dehydrogenase (LDH) activities, measured in the same blood sample, were 84 KU (Karmen units) and 936 lU/liter, respectively. The patient was given 1.5 liters of saline intravenously during the first several hours in the hospital. The following day the patient complained of pain in the thighs, but no muscle swelling was apparent. Body temperature was 37.3°C; blood pressure, 140/72 mm Hg; and pulse, 80/mm. Urine output was 500 ml/ day. Myoglobin was detected in the serum and urine, and myosin was found in the serum. Laboratory examination disclosed the following: hematocrit, 45.0%; hemoglobin, 14.7 g/dl; red blood cell count, 4,960,000/mm3; white blood cell count, 12,000/mm3, of which 75% were neutrophils; platelets, 94,000/mm3; prothrombin time, 63%; serum total protein, 7.6 g/dl; albumin, 4.4 g/dl; plasma fibrinogen, 389 mg/dl; haptoglobin, 170 mg/dl; fasting blood sugar, 80 mg/dl; serum sodium, 136 mEq/liter; potassium, 3.0 mEq/liter; chloride, 99 mEq/liter; arterial blood pH, 7.27; calcium, 9,6 mg/dl; phosphorus, 3.3 mg/dl; BUN, 28 mg/dl; serum creatinine, 4.3 mg/dl; uric acid, 12 mg/dl; GOT, 208 KU; glutamic pyruvic transaminase (GPT), 79 KU; LDH, 1776 lU/liter with predominant isoenzyme type 5. The creatinine phosphokinase (CPK) activity in the serum was too high to measure. Neither fibrin nor fibrinogen degradation products (FDP) were detected in the serum or urine. Plasma renin activity was not measured. Thereafter, BUN and serum creatinine levels increased, although urine output remained between 700 and 1000 ml/day. On the fifth hospital day the following laboratory values were obtained: BUN, 90 mg/dl; serum creatinine, 14.5 mg/dl; GOT, 638 KU; GPT, 171 KU; LDH, 2000 lU/liter; and CPK, 292 lU/liter. Serum sodium was 139 mEq/liter and serum potassium was 4.6 mEq/liter. Prothrombin time was 100%. Potassium exchange resins were administered to prevent hyperkalemia. On the ninth hospital day, the BUN reached 136 mg/dl and the serum creatinine increased to 19.3 mg/dl. The serum sodium concentration fell to 128 mEq/liter and the calcium level to 6.6 mg/dl. Potassium increased to 6.3 mEq/liter despite daily administration of the resins. Serum phosphate concentration was 10.6 mg/dl, and the serum uric acid concentration was 18.4 mg/dl. Peritoneal dialysis was initiated. Approximately 8 days later, polyuria appeared and within 9 more days the BUN fell to 13 mg/dl, serum creatinine to 2.2 mg/dl, and uric acid to 3.6 mg/dl. The forearm ischemic test, performed after renal function had returned to normal, disclosed an appropriate elevation in serum lactate concentration. The patient was discharged on the 64th hospital day, having regained virtually normal renal function.