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Risk Factors for Exertional Rhabdomyolysis with Renal Stress

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Risk Factors for Exertional Rhabdomyolysis with Renal Stress BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2017-000241 on 6 July 2017. Downloaded from Open Access Original article Risk factors for exertional rhabdomyolysis with renal stress Terje Apeland,1 Tore Danielsen,2,3 Eva M Staal,1 Anders A˚sberg,4 Inga S Thorsen,1 Tom Ole Dalsrud,2,5 Stein Ørn6 To cite: Apeland T, ABSTRACT What is known about the subject? Danielsen T, Staal EM, et al. Background Exercise-induced rhabdomyolysis Risk factors for exertional denotes the exertional damage of myocytes with " rhabdomyolysis with renal Exertional rhabdomyolysis is not uncommon and leakage of sarcoplasmic content into the circulation. stress. BMJ Open Sport has been best defined among military personnel, Exerc Med 2017;3:e000241. The purpose of this study was to determine important with incidences from 2.2 to 13.4 cases per doi:10.1136/bmjsem-2017- risk factors for the development of exertional 10 000 persons per year. The US armed forces 000241 rhabdomyolysis in a temperate climate and to study reported a 17% increase in incidental rhabdomy- the renal effects of myoglobinuria. olysis between 2014 and 2015, with the highest Accepted 26 May 2017 Methods A cluster of eight military recruits was incidence rates observed in subjects who were admitted to hospital due to exertional rhabdomyolysis male, younger than 20 years of age, non- with myoglobinuria. The patients were treated Hispanic, recruit trainees or in combat-specific according to current guidelines with isotonic saline and occupations. Furthermore, there are a few civilian alkalinisation of the urine. The eight patients were reports on clusters of rhabdomyolysis among compared with a randomly selected control group of athletes and students. The information on aetio- 26 healthy fellow recruits. All subjects responded to a logical risk factors appears to be sparse and standardised questionnaire. incomplete. Few publications have studied the Results There were little differences in baseline risk factors for the development of this condition. characteristics between patients and controls. In the " It appears that the frequency of associated present study, exercise intensity, duration and type kidney failure is low in otherwise healthy young copyright. were all significant determinants of exertional subjects; a range of 0%–8% has been reported. rhabdomyolysis in univariate models. However, in a Previously, serum creatinine has been used as multivariate model, high exercise intensity on day À1 the main biomarker of kidney injury. Neutrophil was the only significant predictor of rhabdomyolysis gelatinase-associated lipocalin (NGAL) and (p=0.02). All patients had a stable serum creatinine and cystatin C are more sensitive and are early cystatin C. There was a significant increase in serum biomarkers of kidney injury; however, few neutrophil gelatinase-associated lipocalin (NGAL) in the reports have been published in this context. patients, suggesting renal stress. http://bmjopensem.bmj.com/ Conclusions Sustained maximal intensity exercise is a crucial risk factor for rhabdomyolysis with gross pigmenturia. Elevated serum NGAL concentrations What are the new findings? indicate the presence of renal stress. It appears to be possible to quantify the risk of rhabdomyolysis by " Sustained high-intensity physical activity, 1Department of Medicine, means of a simple questionnaire. In the future, this exceeding muscular functional capacity, is a Stavanger University may be used as a tool to prevent rhabdomyolysis. Hospital, Stavanger, Norway crucial risk factor for exertional rhabdomyolysis. 2FSAN, Norwegian Armed " The failure to recognise muscular pain as an Forces, Stavanger, Norway important alarm signal appears to be of impor- 3 Birkenes Medical Centre, INTRODUCTION tance in this setting. on September 27, 2021 by guest. Protected Birkeland, Norway " A simple self-assessment questionnaire may be 4 Rhabdomyolysis denotes the injurious Department of breakdown of skeletal muscle cells. Clini- employed to monitor risk of exertional Transplantation Medicine, rhabdomyolysis. Oslo University Hospital– cally it is characterised by local pain, " Although traditional markers of renal function Rikshospitalet, Oslo, Norway weakness and swelling, with leakage of 5Stavanger Emergency sarcoplasmic content into the circulation, often remain within normal limits in uncompli- Medical Centre, Stavanger, such as creatine kinase (CK), myoglobin cated rhabdomyolysis, elevated serum NGAL may indicate the presence of renal stress Norway and aspartate aminotransferase. The 6Department of Cardiology, or subclinical renal injury. Stavanger University myocytes may be injured in many different Hospital, Stavanger, Norway ways, for example, by mechanical trauma, hypoxia, drugs, toxins or infections.1 Circu- Correspondence to lating myoglobin from injured muscles is significant rhabdomyolysis are often hospi- Dr Terje Apeland; terje. filtered in the kidneys and may cause acute talised and treated with saline infusion and [email protected] kidney damage. Therefore, subjects with bicarbonate.2 Apeland T, et al. BMJ Open Sport Exerc Med 2017;3:e000241. doi:10.1136/bmjsem-2017-000241 1 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2017-000241 on 6 July 2017. Downloaded from Open Access Exertional rhabdomyolysis may be the most common healthy subjects provided blood samples while the form of rhabdomyolysis, particularly in a hot climate.1 patients still were in the hospital (day 3). 3 It may be caused either by direct mechanical injury of the sarcolemma or intracellular energy depletion with Diagnostic criteria for rhabdomyolysis with pigmenturia low ATP, leading to necrosis of muscle cells.4 5 The There should be appropriate clinical findings and exact incidence is unknown, as many patients probably serum CK above 20 000 U/L. The urine should be posi- do not seek medical attention. Furthermore, the diag- tive for blood on dipstick test, but without haematuria nostic criteria may vary. CK concentrations commonly on urine microscopy. rise after strenuous exercise. There is a floating differ- ence between a normal postexercise rise in serum CK and a pathological CK rise due to rhabdomyolysis.6 Treatment Exertional rhabdomyolysis has been best defined The patients were treated according to current guide- among military personnel, with incidences from 2.2 to lines.13 On arrival, they were promptly volume- 13.4 cases per 10 000 persons per year.7 8 The US expanded with intravenous isotonic saline, combined armed forces reported a 17% increase in incidental with drinking water, causing a mean urine output of rhabdomyolysis between 2014 and 2015, with the 5.0 L per day during the hospital stay. The urine was highest incidence rates observed in subjects who were alkalinised with bicarbonate tablets and the mean urine male, younger than 20 years of age, non-Hispanic, pH was 6.9±0.8 during the stay. Patients were recruit trainees or in combat-specific occupations.8 9 discharged when their condition had improved and There are a few civilian reports on clusters of rhabdo- myoglobinuria no longer could be detected with urine myolysis among athletes and students.7 10 11 It appears dipstick test. The mean duration of the hospital treat- that the frequency of associated kidney failure is low in ment was 4.9±0.8 days. otherwise healthy young subjects; 0%–8% has been reported.3 6 7 10 12 Clinical and demographic data collection Most previous studies have focused on the diagnosis and treatment of exertional rhabdomyolysis. Few publi- Both patients and controls responded to a question- cations have studied the risk factors for the naire about their current intake of drugs, tobacco, 10 alcohol, diet and physical training level prior to development of this condition. Exertional rhabdomy- copyright. olysis attenuates physical performance, hampers entering military service. In the same way, information progression of training and adds cost in terms of was obtained about exercise schedule and medical hospitalisations and sick leave. If risk factors are identi- symptoms in the days before the rhabdomyolysis fied, it may be possible to implement preventive cluster occurrence. Data about body weight, height and measures. The primary aim of the present study was to conscription board examinations were extracted from determine the crucial risk factors for the development the military medical record. of exertional rhabdomyolysis in a temperate climate. Prior to military service at conscription board exami- The secondary aim was to assess the renal effects of nation, aerobic capacity and muscular strength were http://bmjopensem.bmj.com/ myoglobinuria by applying novel markers of glomer- assessed with a maximal treadmill running test and two maximum isometric tests for arms and legs.14 The ular filtration (cystatin C) and renal tubular stress results were expressed in a semiquantitative scale from (neutrophil gelatinase-associated lipocalin (NGAL)). 1 to 9, with 1 representing lowest and 9 best results. In the period of muscular injury, the subjects METHODS reported their exercise type on the questionnaire: A: aerobic training; S: strength training; M: mixed Subjects training; No: no exercise. Exercise duration was This is a case–control study based on a cluster of eight reported in minutes. Exercise intensity was reported military recruits who were admitted to the hospital due on September 27, 2021 by guest. Protected on a subjective scale from 1 to 10, with 1 being the to exertional rhabdomyolysis with gross pigmenturia. lowest
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