RHABDOMYOLYSIS progression of aki .pptx

Rhabdomyolysis thesis

1. Department of General Medicine PCMC’S PGI YCMH PIMPRI Pune-18 SYNOPSIS Dr. GNANSHREE PARESH DAVE (Junior resident) Department of General Medicine PG Guide Dr. PRAVIN SONI (Professor & HOD) Department of General Medicine HEAD OF DEPARTMENT Dr. PRAVIN SONI (Professor & HOD) Department of General Medicine

2. Synopsis Title Study of various Renal outcomes –their determining factors and their incidence rates in patients of Rhabdomyolysis : An Observational R etrospective case series study in a Tertiary Care centre. .

3. AIM To study the various Renal outcomes –their determining factors and their incidence rates in patients of Rhabdomyolysis : An Observational Retrospective study in a Tertiary Care centre .

4. INTRODUCTION Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents (electrolytes , myoglobin and sarcoplasmic proteins ) into the circulation Trauma (crush syndrome) is the leading cause of rhabdomyolysis , followed by medical or surgical conditions (heat stroke, immobilization, major artery occlusion, infections, status epilepticus, drugs or genetic defects) 1 L ife-threatening complications include severe hyperkalemia and hypocalcemia, acute kidney injury and hypovolemic shock I n the most severe forms of rhabdomyolysis, mortality rates are high Acute kidney injury (AKI) occurs in about half of patients with rhabdomyolysis, depending on the diagnostic criteria of AKI and the severity of the rhabdomyolysis 2 Ultimately, few patients with rhabdomyolysis will require renal replacement therapy (RRT) After the episode, renal recovery is observed in most survivors but data on the risk of AKI to chronic kidney disease (CKD) transition in this specifc setting are scarce 3

5. INTRODUCTION Rhabdomyolysis is characterized clinically by the triad of myalgias , muscle weakness, and red to brown urine due to myoglobinuria . Biochemically , several serum muscle enzymes are elevated, including CK. Other manifestations include fluid and electrolyte abnormalities; hypovolemia, hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and metabolic acidoses may be seen. Hyperkalemia may result in cardiac dysrhythmias. Later complications include acute kidney injury (AKI), hypercalcemia, compartment syndrome, and, rarely, disseminated intravascular coagulation 4 The McMahon score is a validated scoring system to predict those at higher risk of requiring renal replacement therapy, with a score greater than 6 conferring a risk of renal replacement therapy of 52 %. 5 Critically ill patients with rhabdomyolysis have a high mortality; however, those who survive AKI and RRT are likely to recover to non-dialysis dependent renal function. 6 In this study , we aim to characterize the incidence of AKI in patients with severe rhabdomyolysis, to identify clinically useful predictive factors of KDIGO stage 2–3 AKI, and wanted to provide a special focus over the risk of AKI to CKD transition in these challenging settings.

6. Primary Research Question WHAT ARE THE VARIOUS RENAL OUTCOMES AND THEIR INCIDENCE RATES IN PATIENTS OF RHABDOMYOLYSIS AND WHAT ARE THE FACTORS DETERMINING THESE OUTCOMES ? Primary Hypothesis RHABDOMYOLYSIS PATIENTS HAVE VARYING RENAL OUTCOMES RANGING FROM MORTALITY TO STAGE 2 AND 3 AKI NOT ON HEMODIALYSIS TO AKI PROGRESSING TO CKD AND REQUIRING INTERMITTENT OR CONTINUOUS RRT Primary Objective To characterize the renal outcomes in patients with rhabdomyolysis and estimate the risk of AKI to CKD transition Secondary Objective To determine the incidence rates of various renal outcomes and describe the factors determining them.

7. Methodology Study Design :Observational Retrospective Study Study Duration : Sample Size :

8.   Patients with CKNAC values >1000 or 5 times upper limit of normal. Patients with AKI defined by KDIGO criteria : Increase in serum creatine by 0.3 mg/dl Increase in serum creatinine 1.5 times baseline or more within last 7 days Urine output less than 0.5 ml/kg/ hr for 6 hrs Patients with raised serum or urine myoglobin levels [9,10] Exclusion criteria Patients with ACS/MI and raised CK-MB Patients with cerebro -vascular infarction CVA or IC Bleed (d/t raised CK-BB levels) k/c/o CKD on MHD/ Conservative management. Causes of raised CK other than rhabdomyolysis.   Inclusion criteria

9. Methodology After taking informed consent, the patient’s information will be collected on proforma and complete clinical history , general and systemic examination of the patients will be done.    For our study, following parameters will be studied : COMPLETE BLOOD COUNT OR HEMOGRAM RENAL FUNCTION TEST LIVER FUNCTION TEST SERUM ELECTROLYTES ARTERIAL BLOOD GAS ANALYSIS INCLUDING BICARB AND LACTATE SERUM CALCIUM SERUM PHOSPOROUS MYOGLOBIN SERUM AND URINE SERUM CREATININE KINASE TOTAL SERUM CK-MB URINE ROUTINE MICROSCOPY ULTRASONOGRAPHY ABDOMEN PELVIS        

10. Methodology TO COMPARE OUTCOMES, WE CATEGORIZE PATIENTS OF RHABDOMYOLYSIS INTO 4 DIFFERENT END POINTS A) Patients who were managed conservatively and AKI resolved B) Patients who were initiated on HD but AKI resolved and did not progress to CKD C) Patients who were initiated on HD and progressed to CKD with intermittent or continuous RRT. D) Patients who faced mortality due to complications of rhabdomyolysis. WE CALCULATE PERCENTAGE PROBABILITY OF VARIOUS OUTCOMES and ETIOLOGY BASED ON OUR RETROSPECTIVE OBSERVATIONAL STUDY [7,8,11]

11. REFERENCES Baeza -Trinidad R, Brea-Hernando A, Morera -Rodriguez S, Brito-Diaz Y, Sanchez-Hernandez S, El Bikri L, et al. Creatinine as predictor value of mortality and acute kidney injury in rhabdomyolysis. Intern Med J. 2015;45:1173–8 Rodríguez E, Soler MJ, Rap O, Barrios C, Orfla MA, Pascual J. Risk factors for acute kidney injury in severe rhabdomyolysis. PLoS ONE. 2013;8:e82992. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20:135 Simpson JP, Taylor A, Sudhan N, Menon DK, Lavinio A. Rhabdomyolysis and acute kidney injury: creatine kinase as a prognostic marker and validation of the McMahon Score in a 10-year cohort: a retrospective observational evaluation. Eur J Anaesthesiol . 2016;33:906–12 . McMahon GM, Zeng X, Waikar SS. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013;173:1821–8 Candela N, Silva S, Silva S, et al. Short- and long-term renal outcomes following severe rhabdomyolysis: a French multicenter retrospective study of 387 patients. Ann Intensive Care 2020; 10(1): 27. DOI: 10.1186/s13613-020- 0645-1 Petejova N, and Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care 2014; 18(3): 224. DOI: 10.1186/cc13897 Zeng X, Zhang L, Wu T, et al. Continuous renal replacement therapy (CRRT) for rhabdomyolysis. Cochrane Database Syst Rev 2014; 6: CD008566. DOI: 10.1002/14651858. CD008566.pub2 . Stahl K, Rastelli E, and Schoser B. A systematic review on the definition of rhabdomyolysis. J Neurol 2020; 267: 877–882, DOI: 10.1007/s00415-019-09185-4 Torres PA, Helmstetter JA, Kaye AM, et al. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner Journal 2015; 15(1): 58–69 . Kolovou G, Cokkinos P, Bilianou H, et al. Non-traumatic and non-drug-induced rhabdomyolysis. Arch Med Sci - Atherosclerotic Dis 2019; 4: 252–263. DOI: 10.5114/amsad.2019.90152