Crush-related Acute Kidney Injury Research Articles

Hemodialysis Experience After Kahramanmaraş Earthquake.

Background: Hemodialysis treatment for acute kidney injury associated with crush syndrome is very complex. In our study, we summarized the problems and complications experienced by our hemodialysis center after the Kahramanmaraş earthquake. Methods: After the earthquake, our hospital treated 1396 victims. We evaluated the initial indications for dialysis, hemodialysis complications and the mortality of patients undergoing hemodialysis, including crush-related acute kidney injury (n = 82), during the earthquake period. We also compared them with patients who were undergoing hemodialysis (n = 76) in the same period but had end-stage renal failure and acute kidney injury due to other causes (n = 15). Results: After the earthquake, 173 adult patients, 91 (52.6%) of whom were male, with a mean age of 49.5 + 19.7 years, underwent hemodialysis between 6 and 22 February 2023. Patients with crush-related acute kidney injury experienced more complications during hemodialysis, and the increase in creatine kinase activity increased the risk of hemodialysis complications. The most common complications were blood clots in the dialyzer membrane, intradialytic hypotension, and intradialytic insufficient flow. The most frequent indication for initial hemodialysis was hyperkalemia (61, 74.4%). The major problems in the hemodialysis center included inadequate equipment and an insufficient number of experienced health personnel. Conclusions: Hyperkalemia is the most important initial indication for hemodialysis in patients with crush-related acute kidney injury. Crush-related acute kidney injury patients require hemodialysis more frequently, and hemodialysis complications are higher in patients with crush-related AKI, so the hemodialysis treatment of these patients should be more cautious. In an earthquake, hemodialysis centers may face significant challenges, such as damage, transportation issues, power outages, and water outages, which can hinder hemodialysis treatment.

Pediatric crush-related acute kidney injury and risk factors: asingle center experience.

Crush injury, the most important trauma complicationencountered in earthquake victims, occurs as a result of prolonged compression of muscle mass. Crush syndrome, resultingfrom crushinjury, and acute kidney injury (AKI) are the most common causes of in-hospital deaths after earthquakes. The aim of this study is to convey our experience afterthe devastating Turkey-Syria earthquake and to identify the risk factors of crush syndrome and crush-related AKI. Of the 1134 children admitted to the emergency department, 265 with crush injury were included the study. Demographic information, laboratory and clinical data of the patients were retrospectively analyzed. Mean age of the patientswas 10.3 ± 4.9years (134 femalesand131 males). The median time spent under the rubble was 20h. Crush syndrome developed in 135 (50.9%). Patients with crush syndrome were older and had higher body weight, respectively (p = 0.014, p = 0.044). Acute kidney injury was present in 157 (59.2%) patients. Thirty-two patients (12.1%) received kidney replacement therapy (KRT). The risk factors for the development of AKI Stage 3 were crush syndrome, abdominal trauma, and age. This disaster taught us the importance of establishing in advancea national emergency disaster plan. Older pediatric earthquake victims with multiple trauma and severe crush syndrome should be closely followed-up for development of AKI and, if necessary, started on dialysis. Timely access to medical care, early fluid resuscitation, and effective use of dialysis treatment are essential.

A Comparative Analysis of Fasciotomy Results in Children and Adults Affected by Crush-Induced Acute Kidney Injury following the Kahramanmaraş Earthquakes.

Background and Objectives: The current study aims to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having an acute kidney injury (AKI). Patients with an AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between 4 and 83 years. A total of 21 patients underwent fasciotomy, and the patients underwent varying numbers of fasciotomy, ranging from 0 to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.

Management of Crush-related Acute Kidney Injury After Disasters.

Management of Crush-related Acute Kidney Injury After Disasters.

Beneficial effects of bardoxolone methyl, an Nrf2 activator, on crush-related acute kidney injury in rats.

The purpose of this study was to investigate the effects of bardoxolone methyl (BM), a nuclear factor erythroid 2-related factor 2 (Nrf2) activator, on acute kidney injury in a rat model of crush syndrome model. Sixty-four rats were separated equally into eight groups, sham (sterile saline ip), crush, crush + vehicle (DMSO ip), and crush + BM (10mg/kg ip) (n = 8). All groups were also divided as 3 and 24h after decompression. Crush injury was induced by 6h of direct compression to both hind limbs of the rats with blocks weighing 3.6kg on each side, followed by 3 and 24h of decompression. Kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), tumor necrotizing factor-α (TNF-α), transforming growth factor-β1 (TGF-β1) concentrations, tissue total oxidant status (TOS) and total antioxidant status (TAS) were measured in the kidneys. Serum creatine kinase (CK), blood urea nitrogen (BUN) and creatinine concentrations were also measured. Glomerular and tubular structures were examined histopathologically. Bcl-2 was measured using immunohistochemistry. Apoptosis was assessed using the TUNEL method. BM treatment reduced KIM-1, NGAL, TNF-α, TGF-β1, TOS concentrations, and increased TAS concentrations in the kidneys 3 and 24h after decompression. Serum CK, BUN and creatinine concentrations were also reduced with BM. BM treatment decreased apoptosis in crush-related AKI. The Nrf2 activator BM reversed the crush-induced changes in the experimental rats. BM treatment prevented the progression of crush-related AKI in rats possibly through its cytoprotective effects of being an antioxidant, anti-inflammatory and anti-apoptotic agent.

Effect of Hydrogen Sulfide on Kidney Injury in Rat Model of Crush Syndrome

BackgroundAcute kidney injury is the most serious complication of crush syndrome. Hydrogen sulfide (H2S) is an endogenously produced gaseous signaling molecule. It is involved in homeostatic functions, such as blood pressure control, apoptosis, oxidative stress, and inflammation. In this study, effects of H2S on kidney injury were investigated in a rat model of crush syndrome. MethodsRats were divided into six groups (n = 8): Sham (steril saline ip), crush (sterile saline ip), crush + NaHS (sodium hydrosulfide, an H2S donor) (100 μmol/kg ip). All these groups were also separated as 3 and 24 h after decompression. Crush injury was induced by 6 h of direct compression to both hindlimbs of anesthetized rats with blocks weighing 3.6 kg each sides, followed by 3 or 24 h of decompression. Kidney injury molecule-1, neutrophil gelatinase–associated lipocalin, tumor-necrotizing factor-α, transforming growth factor-β, tissue total oxidant status, and total antioxidant status levels were measured in kidney homogenates 3 and 24 h after decompression. Serum creatine kinase, blood urea nitrogen, and creatinine levels were also measured. Apoptosis was assessed by TUNEL method. Bcl-2 was assessed by immunohistochemistry. Glomerular and tubular structures were also examined histopathologically. ResultsNaHS reduced kidney injury molecule-1, neutrophil gelatinase–associated lipocalin, tumor-necrotizing factor-α, transforming growth factor-β, total oxidant status levels, and increased total antioxidant status levels in kidney 3 and 24 h after decompression. Serum urea, creatinine, and creatine kinase levels also reduced with NaHS. NaHS decreased renal damage and apoptosis in crush-related acute kidney injury. ConclusionsThese results suggest that H2S could reduce crush-related acute kidney injury via anti-inflammatory, antioxidant, and antiapoptotic effects.

Non-machinery dialysis that achieves blood purification therapy without using full-scale dialysis machines.

An electrical or water supply and a blood purification machine are required for renal replacement therapy. There is a possibility that acute kidney injury can occur in large numbers and on a wide scale in the case of a massive earthquake, and there is the potential risk that the current supply will be unable to cope with acute kidney injury cases. However, non-machinery dialysis requires exclusive circuits and has the characteristic of not requiring the full-scale dialysis machines. We performed perfusion experiments that used non-machinery dialysis and recent blood purification machines in 30-min intervals, and the effectiveness of non-machinery dialysis was evaluated by the assessing the removal efficiency of potassium, which causes lethal arrhythmia during acute kidney injury. The non-machinery dialysis potassium removal rate was at the same level as continuous blood purification machines with a dialysate flow rate of 5L/h after 15min and continuous blood purification machines with a dialysate flow rate of 3L/h after 30min. Non-machinery dialysis required an exclusive dialysate circuit, the frequent need to replace bags, and new dialysate exchanged once every 30min. However, it can be seen as an effective renal replacement therapy for crush-related acute kidney injury patients, even in locations or facilities not having the full-scale dialysis machines.

Accuracy of urine dipstick in the detection of patients at risk for crush-induced rhabdomyolysis and acute kidney injury

To evaluate the utility of urine dipstick test (UDT) for detecting rhabdomyolysis and acute kidney injury (AKI) due to crush injury. All the rescued victims of the Bam earthquake who had a documented urine analysis and serum creatine phosphokinase and creatinine levels during their hospitalization period were eligible to enter the study. The sensitivity and the specificity, along with the positive and negative likelihood ratios, of UDT in detecting at-risk patients for rhabdomyolysis and crush-related AKI were calculated. Urine red blood cell count of 5 or less in blood-positive UDT, as a surrogate marker for myoglobinuria, was reported in 210 (31.7%) of the total 1821 urine analyses. Blood-positive UDTs (without considering the urine red blood cell count) had a 92.5% (95% confidence interval: 79.6-98.4) sensitivity in creatine phosphokinase, with a cut-off of 15,000 (IU/l). Comparing the results of the serum creatinine level and the urine blood, analysis showed that UDT had a sensitivity and a specificity of as high as 83.3 and 56.6% in detecting high-risk patients for AKI, respectively. UDT can be considered as an early screening tool for the detection and triage of patients at risk of developing AKI because of traumatic rhabdomyolysis after mass disasters.

Levels of Neutrophil Gelatinase-Associated Lipocalin in 2 Patients With Crush Syndrome After a Mudslide

Neutrophil gelatinase-associated lipocalin is one of the most promising biomarkers for the diagnosis of acute kidney injury. An increase in the level of neutrophil gelatinase-associated lipocalin is a good predictor of acute kidney injury and is associated with an increase in the serum level of creatinine. Two victims of a mudslide in Messina, Italy, initially had crush syndrome followed by development of acute kidney injury. The development of acute kidney injury is the second most common cause of death after large earthquakes and other natural disasters, but at the same time, crush-related acute kidney injury is one of the few life-threatening complications of crush injuries that can be reversed if diagnosed early and treated. In this case, measuring the level of neutrophil gelatinase-associated lipocalin enabled early diagnosis of acute kidney injury and anticipation of the changes in levels of conventional markers such as creatinine.

Dialysis practice and patient outcome in the aftermath of the earthquake at L'Aquila, Italy, April 2009

In the aftermath of large natural and manmade disasters, the need for continuing maintenance haemodialysis (HD) in end-stage renal disease patients of the disaster area and care including dialysis for patients suffering from acute kidney injury (AKI) due to crush syndrome are the two most important nephrological problems. We report on how renal patients and renal care personnel faced emergency in the aftermath of the earthquake that struck the Italian town of L'Aquila and a surrounding district, on Monday 6 April 2009, causing 308 deaths, some 1500 injured and 66,000 people to be displaced. The Dialysis Centre in the town did not collapse but was seriously damaged and out of action, making it necessary to move 88 patients on regular dialysis treatment to the closest available facilities to continue treatment. This was all the more urgent in that 45 patients of the Monday-Wednesday-Friday batch were coming off the long interdialytic interval, with possible medical problems (i.e. high increase in weight gain, blood pressure, etc.). In spite of manifold difficulties (including road interruption and shortage of means of transportation, problems in establishing contact between patients and care personnel due to failure of phone and electronic communication and the limited number of available dialysis posts), no patient missed any scheduled HD session. This was obtained thanks to the transfer of patients to neighbouring functioning units, often with extra dialysis shifts. In 3 days, a provisional Dialysis Centre was set up in an inflatable military-style tent, enabling 780 dialysis sessions to be performed safely on patients who had opted to return to L'Aquila. The tent facility was replaced by a rigid modular structure, insulated as living accommodation, containing 13 dialysis machines (20 from 17 November) functioning in HD or on-line haemodiafiltration. Ten cases of crush-related AKI needing dialysis treatment were recorded, the ratio of dialysed victims to number of deaths (32.4: 10 cases/308 deaths, 1000×) being the highest value yet reported. Fasciotomy was performed in six patients but none of the patients had to be amputated. Intermittent HD was used in most cases as the single modality of renal replacement therapy. All patients survived and recovered renal function on discontinuing dialysis treatment. Serum creatinine returned to normal values upon discharge from hospital or during the follow-up period. Each earthquake is different and may pose issues that will require unanticipated response efforts. Advance planning and rescue coordination, flexibility and creativity in the emergency situation, as well as the hard work and dedication of the entire dialysis care community, contributed to the remarkably positive outcome of dialysis-needing patients in the aftermath of the Aquila earthquake.

Application of the RIFLE criteria in patients with crush-related acute kidney injury after mass disasters

The term acute kidney injury (AKI) and its classification in strata defined as Risk, Injury, Failure, Loss and End-stage renal failure (RIFLE) need to be validated in different patient groups. RIFLE may be useful to foresee medical and logistic problems in crush-related AKI in disaster victims. Taken from the Marmara earthquake crush database, the subjects included 416 patients who were categorized according to the modified RIFLE criteria and 18 victims with crush injury but with normal serum creatinine who served as controls. Associations between each RIFLE category and various parameters were investigated. There were 27, 79 and 310 patients in the risk, injury and failure groups, respectively. Urine volume and serum albumin were lower; blood pressure, blood urea nitrogen, serum uric acid, potassium and phosphorus were higher; oliguric and polyuric periods were longer; medical complications were more frequent; and number of transfusions, dialysis sessions and days of dialysis support were higher in more severe AKI categories. Glomerular filtration rate at discharge was progressively lower in proportion to the severity of RIFLE classification. However, survival outcome did not differ among controls and patients who suffered from AKI nor in between RIFLE categories. In disaster crush victims, RIFLE classification can be useful to foresee the medical complications, need for therapeutic interventions and logistic support and also renal function at discharge though, perhaps, not survival.

Impact of local circumstances on outcome of renal casualties in major disasters

In the aftermath of earthquakes, the cumulative incidence of crush-induced acute kidney injury (AKI) is difficult to predict. Insight into factors determining this risk is indispensable to allow adequate logistical planning, which is a prerogative for success in disaster management. Data of 88 crush-related AKI patients in the aftermath of the Kashmir earthquake were collected and outcome measures were analysed. Then the findings were compared with the data of 596 crush-related AKI patients of the Marmara earthquake. The earthquake in Kashmir occurred in a rural area with lack of medical facilities and difficult transportation conditions while the earthquake in Marmara occurred in an urban area with more efficient transport possibilities. In Kashmir we reported fewer patients with treated AKI (1.2 AKI per 1000 deaths, 1.3 AKI per 1000 victims) than in Marmara (34.1 AKI per 1000 deaths; P < 0.001, 13.6 AKI per 1000 victims; P < 0.001). Time lag between earthquake and admission to hospitals was longer in Kashmir (5.8 +/- 5.8 days) than in Marmara (3.5 +/- 3.7 days; P < 0.001). The frequencies of fasciotomies (P < 0.001), amputations (P < 0.001) and dialysis (P = 0.005) were lower in Kashmir, than in Marmara AKI patients. The cumulative incidence of treated AKI related to number of deaths or victims might differ substantially among earthquakes. Many factors may affect the frequency of AKI: hampered rescue and transport possibilities; destroyed medical facilities on the spot; availability or not of sophisticated therapeutic possibilities and structure of the buildings might all have impacted on different cumulative incidence between Kashmir and Marmara.