今日の臨床サポート

横紋筋融解症

著者: 加藤之紀 医療法人EMS 植田救急クリニック

監修: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

著者校正/監修レビュー済:2021/01/28
患者向け説明資料

概要・推奨   

  1. 横紋筋融解とは内因性、外因性を含め種々の原因により筋細胞が障害され、ミオグロビンなどの内容物が体循環に漏出して全身に影響を及ぼす病態である。
  1. 横紋筋融解の診断は血清CKの上昇とミオグロビン尿の検出から行われる。血清CKの横紋筋融解における明確な基準はないが慣習的に正常値の5~10倍が目安とされる。ミオグロビン尿の検出は尿試験紙での潜血反応陽性と沈査での赤血球陰性の解離から簡易的に推定る。しかし血清CK値は発症から遅れて上昇するため評価には注意が必要となる。
  1. 横紋筋融解の合併症として電解質異常、急性腎不全、播種性血管内凝固症候群などが挙げられ、急性腎不全は横紋筋融解の10~65%程度に合併するが、その発症は予後不良因子の1つである。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
加藤之紀 : 特に申告事項無し[2021年]
監修:志賀隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、一部構成を変更した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 横紋筋融解とは、外傷などの種々の原因により筋細胞が壊死し、その内容物が体循環に漏出して全身に影響を及ぼす病態である。
 
横紋筋融解症のQuick View

出典

img1:  著者提供
 
 
 
  1. 原因としては長時間の筋圧迫や外傷に加え、過度の運動や感染、薬物などが挙げられる。
  1. 外傷による筋挫滅由来の横紋筋融解はクラッシュ症候群と呼ばれ、1995年の阪神・淡路大震災の際には発生後15日以内に372人が発症した[1]
  1. 主に血清CKの上昇で診断する。明確な基準値はないが慣習的に正常値の5~10倍が1つの目安とされる。
  1. ミオグロビン尿:<図表>
  1. 全身への合併症としては、血管内脱水や漏出したミオグロビンの尿細管や腎血管への影響による 急性腎不全 が代表的であり、予後を左右する。発症率は報告によってばらつきはあるが横紋筋融解の10~50%ほどで起こるといわれる[2][3][4]
  1. 横紋筋融解による腎毒性の機序としては、循環血漿量低下によるレニンアンジオテンシン系の賦活からの血管収縮とそれに続く腎血流量低下、酸性尿下での円柱形成、尿酸による尿細管障害、活性酸素産生による尿細管障害等が考えられている[5][6]
  1. 筋細胞内電解質の体循環への漏出による種々の電解質異常も起こり、特に高カリウム血症は不整脈を引き起こし致死的になることがある。
  1. 腎不全への発展防止、治療に際しては早期の積極的な細胞外液点滴が推奨される[7][8][9][10][11][12][13]
問診・診察のポイント  
  1. 長時間の筋圧迫や外傷歴、過度の運動など、筋肉に直接損傷を与える病歴がないか確認する。

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文献 

著者: J Oda, H Tanaka, T Yoshioka, A Iwai, H Yamamura, K Ishikawa, T Matsuoka, Y Kuwagata, A Hiraide, T Shimazu, H Sugimoto
雑誌名: J Trauma. 1997 Mar;42(3):470-5; discussion 475-6.
Abstract/Text OBJECTIVE: To clarify clinical features and determine the severity of injuries in patients with crush syndrome in Hanshin-Awaji earthquake.
METHODS: We retrospectively reviewed medical records of 6,107 patients hospitalized in 95 hospitals, and identified 372 patients with crush syndrome.
RESULTS: The major sites of crush injury were in the lower extremities (74%), followed by the upper extremities (10%), and the trunk (9%). Pelvic fractures, limb fractures, and abdominal injuries were the most frequently associated injury. Patients with trunk compression and/or with abdominal injury had a higher mortality rate. A total of 50 patients (13.4%) died. The causes of death within 5 days after the earthquake were hypovolemia and hyperkalemia. Peak serum creatine kinase concentration increased with the number of crushed extremities. Mortality and the risk of acute renal failure were higher in patients with creatine kinase concentration more than 75,000 micro/L.
CONCLUSIONS: Peak serum concentration of creatine kinase as well as the number of injured extremities serve to estimate the severity of crush syndrome.

PMID 9095115  J Trauma. 1997 Mar;42(3):470-5; discussion 475-6.
著者: Arthur R de Meijer, Bernard G Fikkers, Marinus H de Keijzer, Baziel G M van Engelen, Joost P H Drenth
雑誌名: Intensive Care Med. 2003 Jul;29(7):1121-5. doi: 10.1007/s00134-003-1800-5. Epub 2003 May 24.
Abstract/Text OBJECTIVE: To evaluate the risk factors for the development of acute renal failure (ARF) in severe rhabdomyolysis.
DESIGN: Observational historical cohort study.
SETTING: General intensive care unit of a university hospital.
PATIENTS: Twenty-six patients with severe rhabdomyolysis, who were admitted between July 1996 and July 2001.
MEASUREMENTS AND RESULTS: Clinical and laboratory data were reviewed and groups were stratified according to presence or absence of acute renal failure. The underlying cause of rhabdomyolysis was ischemia by vascular obstruction (50%), crush injury by trauma (23%), sepsis (11.5%), heatstroke/hyperthermia (11.5%) and hyponatremia in a single patient. Mean creatine kinase (CK) level was 38,351+/-35,354 U/l on admission and rose further in all patients (mean: 59,747+/-67,514 U/l). Renal failure developed in 17 patients (65%). Serum CK levels correlated with onset of ARF, as these patients had significantly higher admission and peak serum CK concentrations. Patients with ARF had a higher mortality (59% vs 22%).
CONCLUSION: In our cohort of patients with severe rhabdomyolysis the level of serum CK predicted the development of ARF. Although our results suggest that series of CK determination might be beneficial for the evaluation of the effect of therapy, the value of CK determination as a prognostic tool is limited, given the wide range of CK levels.

PMID 12768237  Intensive Care Med. 2003 Jul;29(7):1121-5. doi: 10.1007・・・
著者: Carlos V R Brown, Peter Rhee, Linda Chan, Kelly Evans, Demetrios Demetriades, George C Velmahos
雑誌名: J Trauma. 2004 Jun;56(6):1191-6.
Abstract/Text BACKGROUND: The combination of bicarbonate and mannitol (BIC/MAN) is commonly used to prevent renal failure (RF) in patients with rhabdomyolysis despite the absence of sufficient evidence validating its use. The purpose of this study was to determine whether BIC/ MAN is effective in preventing RF in patients with rhabdomyolysis caused by trauma.
METHODS: This study was a review of all adult trauma intensive care unit (ICU) admissions over 5 years (January 1997-September 2002). Creatine kinase (CK) levels were checked daily (abnormal,>520 U/L). RF was defined as a creatinine greater than 2.0 mg/dL. Patients received BIC/MAN on the basis of the surgeon's discretion.
RESULTS: Among 2,083 trauma ICU admissions, 85% had abnormal CK levels. Overall, RF occurred in 10% of trauma ICU patients. A CK level of 5,000 U/L was the lowest abnormal level associated with RF; 74 of 382 (19%) patients with CK greater than 5,000 U/L developed RF as compared with 143 of 1,701 (8%) patients with CK less than 5,000 U/L (p < 0.0001). Among patients with CK greater than 5,000 U/L, there was no difference in the rates of RF, dialysis, or mortality between those who received BIC/MAN and those who did not. Subanalysis of groups with various levels of CK still failed to show any benefit of BIC/MAN.
CONCLUSION: Abnormal CK levels are common among critically injured patients, and a CK level greater than 5,000 U/L is associated with RF. BIC/MAN does not prevent RF, dialysis, or mortality in patients with creatine kinase levels greater than 5,000 U/L. The standard of administering BIC/MAN to patients with post-traumatic rhabdomyolysis should be reevaluated.

PMID 15211124  J Trauma. 2004 Jun;56(6):1191-6.
著者: M M Ward
雑誌名: Arch Intern Med. 1988 Jul;148(7):1553-7.
Abstract/Text In a historical cohort study, acute renal failure developed in 16.5% of 157 patients with rhabdomyolysis over a two-year study period. Underlying clinical, laboratory, and causative factors associated with the development of acute renal failure were examined. Factors predictive of renal failure in this setting, determined by multiple logistic regression analysis, included the degree of serum creatine kinase, serum potassium, and serum phosphorus level elevation; the degree of depression of serum albumin level; and the presence of dehydration at presentation or sepsis as the underlying cause. The predictive model that was developed correctly classified 93% of subjects and was statistically validated.

PMID 3382301  Arch Intern Med. 1988 Jul;148(7):1553-7.
著者: Luis O Chavez, Monica Leon, Sharon Einav, Joseph Varon
雑誌名: Crit Care. 2016 Jun 15;20(1):135. doi: 10.1186/s13054-016-1314-5. Epub 2016 Jun 15.
Abstract/Text BACKGROUND: Rhabdomyolysis is a clinical syndrome that comprises destruction of skeletal muscle with outflow of intracellular muscle content into the bloodstream. There is a great heterogeneity in the literature regarding definition, epidemiology, and treatment. The aim of this systematic literature review was to summarize the current state of knowledge regarding the epidemiologic data, definition, and management of rhabdomyolysis.
METHODS: A systematic search was conducted using the keywords "rhabdomyolysis" and "crush syndrome" covering all articles from January 2006 to December 2015 in three databases (MEDLINE, SCOPUS, and ScienceDirect). The search was divided into two steps: first, all articles that included data regarding definition, pathophysiology, and diagnosis were identified, excluding only case reports; then articles of original research with humans that reported epidemiological data (e.g., risk factors, common etiologies, and mortality) or treatment of rhabdomyolysis were identified. Information was summarized and organized based on these topics.
RESULTS: The search generated 5632 articles. After screening titles and abstracts, 164 articles were retrieved and read: 56 articles met the final inclusion criteria; 23 were reviews (narrative or systematic); 16 were original articles containing epidemiological data; and six contained treatment specifications for patients with rhabdomyolysis.
CONCLUSION: Most studies defined rhabdomyolysis based on creatine kinase values five times above the upper limit of normal. Etiologies differ among the adult and pediatric populations and no randomized controlled trials have been done to compare intravenous fluid therapy alone versus intravenous fluid therapy with bicarbonate and/or mannitol.

PMID 27301374  Crit Care. 2016 Jun 15;20(1):135. doi: 10.1186/s13054-0・・・
著者: Nadezda Petejova, Arnost Martinek
雑誌名: Crit Care. 2014 May 28;18(3):224. doi: 10.1186/cc13897. Epub 2014 May 28.
Abstract/Text Rhabdomyolysis, a clinical syndrome caused by damage to skeletal muscle and release of its breakdown products into the circulation, can be followed by acute kidney injury (AKI) as a severe complication. The belief that the AKI is triggered by myoglobin as the toxin responsible appears to be oversimplified. Better knowledge of the pathophysiology of rhabdomyolysis and following AKI could widen treatment options, leading to preservation of the kidney: the decision to initiate renal replacement therapy in clinical practice should not be made on the basis of the myoglobin or creatine phosphokinase serum concentrations.

PMID 25043142  Crit Care. 2014 May 28;18(3):224. doi: 10.1186/cc13897.・・・
著者: T Shimazu, T Yoshioka, Y Nakata, K Ishikawa, Y Mizushima, F Morimoto, M Kishi, M Takaoka, H Tanaka, A Iwai, A Hiraide
雑誌名: J Trauma. 1997 Apr;42(4):641-6.
Abstract/Text BACKGROUND: Crush syndrome is a form of traumatic rhabdomyolysis characterized by systemic involvement, in which acute renal failure is potentially life-threatening.
METHODS: Clinical and laboratory data of 14 crush-syndrome patients transferred to a tertiary emergency department after the Hanshin-Awaji earthquake were analyzed. The patients were buried under collapsed houses for the average of 6.7 +/- 5.7 (SD) hours (range, 1 to 24 hours). They were referred to us 6 to 250 hours after the earthquake.
RESULTS: Of those who arrived at our institution within 40 hours, 25% (two of eight) developed renal failure, whereas all six patients who arrived after 40 hours developed renal failure. Peak serum creatine kinase ranged from 6,677 to 134,200 U/L (51,674 +/- 41,776). Renal failure was highly associated with massive muscle damage (serum creatine kinase above 25,000 U/L) and insufficient initial fluid resuscitation (below 10,000 mL/2 days).
CONCLUSIONS: Prompt and adequate, if not massive, fluid resuscitation is the key to preventing renal failure after such injury.

PMID 9137251  J Trauma. 1997 Apr;42(4):641-6.
著者: D Ron, U Taitelman, M Michaelson, G Bar-Joseph, S Bursztein, O S Better
雑誌名: Arch Intern Med. 1984 Feb;144(2):277-80.
Abstract/Text Following the collapse of a building, seven subjects (aged 18 to 41 years) were released from under the rubble within one to 28 hours. All seven suffered from extensive crush injuries with evidence of severe rhabdomyolysis and were treated by the induction of an alkaline solute diuresis immediately on their extrication from the debris. The leakage of muscle constitutents was estimated by quantifying the net total body potassium losses, which averaged 395 mEq (SD, +/- 198) over the first 60 hours of therapy. In the past, injuries of similar severity have been associated with a high incidence of acute renal failure and a high mortality rate, yet none of our patients had azotemia or renal failure. We attribute this success to the unprecedented early institution of appropriate therapy.

PMID 6696564  Arch Intern Med. 1984 Feb;144(2):277-80.
著者: Lütfullah Altintepe, Ibrahim Guney, Zeki Tonbul, Süleyman Türk, Mehmet Mazi, Erhan Ağca, Mehdi Yeksan
雑誌名: Ren Fail. 2007;29(6):737-41. doi: 10.1080/08860220701460095.
Abstract/Text BACKGROUND: Crush syndrome developing as a result of earthquake and other natural disasters has been investigated from many angles to date. Data are scarce, however, on cases associated with the spontaneous crash of buildings. This study presents the results on seven rhabdomyolysis patients treated in our clinics out of nine casualties who were rescued from the rubble of Zümrüt apartment after the building collapsed suddenly and spontaneously.
METHODS: As a result of the sudden, spontaneous collapse of the 10-floor Zümrüt apartment in Konya at 20:15 hours on February 2, 2004, 92 out of a total of 121 persons who were inside the building lost their lives, and 29 casualties were rescued from the rubble. Nine hospitalized patients had crush syndrome, and a prophylactic mannitol-bicarbonate cocktail was started in all at admission.
RESULTS: The time they remained entrapped under the rubble was 11.1 +/- 7.3 (5-24 hours) on average. The highest CPK level of the patients was 79049 +/- 75374 u/L (17478-223600 u/L), observed on the median day 1.7 +/- 1.1 (days 1-4) following the incident. ARF developed in only two cases (28.6%) owing to the prophylactic mannitol-bicarbonate cocktail administered to prevent ARF, and because of hyperpotassemia, hemodialysis (HD) treatment was administered to these patients. One patient required two sessions of HD, and another required four. In both patients who received HD treatment, the level of potassium was in excess of 7 mEq/L. A total of eight fasciotomies were performed on five (71.4%) of the seven patients with crush syndrome. Five of the fasciotomies (62.5%) were performed on two of our patients who required HD treatment. None of our patients with crush syndrome developed permanent kidney damage, and no mortality occurred.
CONCLUSION: It was deduced that rapid fluid therapy accompanied by the prophylactic administration of mannitol-bicarbonate are largely effective in preventing the development of ARF in cases with crush syndrome resulting from disasters.

PMID 17763170  Ren Fail. 2007;29(6):737-41. doi: 10.1080/0886022070146・・・
著者: Ali Ihsan Gunal, Huseyin Celiker, Ayhan Dogukan, Goksel Ozalp, Ercan Kirciman, Huseyin Simsekli, Izzettin Gunay, Mustafa Demircin, Oktay Belhan, Mustafa A Yildirim, Mehmet S Sever
雑誌名: J Am Soc Nephrol. 2004 Jul;15(7):1862-7.
Abstract/Text This study analyzes the effects of fluid resuscitation in the crush victims of the Bingol earthquake, which occurred in May 2003 in southeastern Turkey. Questionnaires asking about demographic, clinical, laboratory, and therapeutic features of 16 crush victims were filled in retrospectively. Mean duration under the rubble was 10.3 +/- 7 h, and all patients had severe rhabdomyolysis. Fourteen patients were receiving isotonic saline at admission, which was followed by mannitol-alkaline fluid resuscitation. All but two patients were polyuric. Admission serum creatinine level was lower than and higher than 1.5 mg/dl in 11 and 5 patients, respectively. Marked elevations were noted in muscle enzymes in all patients. During the clinical course, hypokalemia was observed in nine patients, all of whom needed energetic potassium chloride replacement. Four (25%) of 16 victims required hemodialysis. Duration between rescue and initiation of fluids was significantly longer in the dialyzed victims as compared with nondialyzed ones (9.3 +/- 1.7 versus 3.7 +/- 3.3 h, P < 0.03). Sixteen fasciotomies were performed in 11 patients (68%), nine of which were complicated by wound infections. All patients survived and were discharged from the hospital with good renal function. Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.

PMID 15213274  J Am Soc Nephrol. 2004 Jul;15(7):1862-7.
著者: O S Better, J H Stein
雑誌名: N Engl J Med. 1990 Mar 22;322(12):825-9. doi: 10.1056/NEJM199003223221207.
Abstract/Text
PMID 2407958  N Engl J Med. 1990 Mar 22;322(12):825-9. doi: 10.1056/N・・・
著者: M Odeh
雑誌名: N Engl J Med. 1991 May 16;324(20):1417-22. doi: 10.1056/NEJM199105163242007.
Abstract/Text The crush syndrome consists of the general manifestations that follow prolonged continuous pressure on the limbs. These manifestations are caused by the disintegration of muscle tissue and leakage of the contents of myocytes into the plasma. The morbidity and mortality associated with this syndrome are high. The pathophysiologic process of the derangements associated with the crush syndrome is not fully understood, but the injury induced by reperfusion is likely to be important in its development. The injury due to reperfusion involves many factors, but it is currently ascribed largely to the release of oxygen free radicals, massive accumulation of calcium in ischemic muscles, and the infiltration of neutrophils into reperfused vessels. Since ischemic muscles cannot survive without reperfusion, a strategy to salvage as much of the muscle and kidney tissue as possible in the crush syndrome must include ways of decreasing injury during ischemia and reperfusion. Various pharmacologic agents may attenuate or prevent reperfusion-induced injury to ischemic skeletal muscles and consequently to other organs, particularly the kidneys.

PMID 2020298  N Engl J Med. 1991 May 16;324(20):1417-22. doi: 10.1056・・・
著者: O Demirkiran, Y Dikmen, T Utku, S Urkmez
雑誌名: Emerg Med J. 2003 May;20(3):247-50.
Abstract/Text BACKGROUND: To assess the treatment and outcome of patients with crush injury sustained in the Marmara earthquake.
METHODS: Seven hundred eighty three patients were transferred to a university hospital and 25 of them were admitted to the intensive care unit. The medical records of 18 crush injury patients were retrospectively reviewed.
RESULTS: The major associated injuries were in the lower extremities, upper extremities, and chest. Seven patients underwent fasciotomy and six patients had amputations. Twelve patients required mechanical ventilation. Adult respiratory distress syndrome developed in four patients. Oliguria occurred in eight patients. Hyperkalaemia was seen in six patients and four of them underwent emergency haemodialysis. One patient died because of hyperkalaemia on arrival to the intensive care unit. Renal failure was treated with haemodialysis or haemoperfusion in 13 patients. Five patients died because of multiple organ failure and two patients because of sepsis.
CONCLUSION: Crush syndrome is a life threatening event. The authors believe that early transportation and immediate intensive care therapy would have improved the survival rate.

PMID 12748140  Emerg Med J. 2003 May;20(3):247-50.
著者: Edward J Newton, John Love
雑誌名: Emerg Med Clin North Am. 2007 Aug;25(3):751-61, iv. doi: 10.1016/j.emc.2007.06.003.
Abstract/Text In addition to the large number of patients with isolated limb injuries, many patients with major blunt or penetrating trauma harbor extremity injuries as a component of their overall clinical picture. Extremity injuries range from gross deformities and amputations to more subtle injuries, potentially difficult to diagnose, or may escape detection in unconscious or intoxicated patients. However, many soft tissue and vascular injuries require time sensitive interventions to ensure salvage of the limb and the best outcome for the patient. This article reviews the acute management of vascular and soft tissue injuries in the emergency department.

PMID 17826216  Emerg Med Clin North Am. 2007 Aug;25(3):751-61, iv. doi・・・
著者: Michael Frink, Frank Hildebrand, Christian Krettek, Jurgen Brand, Stefan Hankemeier
雑誌名: Clin Orthop Relat Res. 2010 Apr;468(4):940-50. doi: 10.1007/s11999-009-0891-x. Epub 2009 May 27.
Abstract/Text UNLABELLED: Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary.
LEVEL OF EVIDENCE: Level III. See Guidelines for Authors for a complete description of levels of evidence.

PMID 19472025  Clin Orthop Relat Res. 2010 Apr;468(4):940-50. doi: 10.・・・
著者: Davinder S Grover, Mohamed G Atta, Joseph A Eustace, Thomas S Kickler, Derek M Fine
雑誌名: Nephrol Dial Transplant. 2004 Oct;19(10):2634-8. doi: 10.1093/ndt/gfh422. Epub 2004 Jul 27.
Abstract/Text BACKGROUND: In the diagnosis of rhabdomyolysis, the microconcentrator qualitative assay for urine myoglobin (uMb) is often used as a screening tool. The accuracy and clinical utility of this assay in screening patients with rhabdomyolysis have not been examined.
METHODS: We conducted a retrospective analysis of the relationship between creatine kinase (CK), serum myoglobin (sMb), the urine qualitative assay for myoglobin and the semi-quantitative assay for urine haem pigments (uH) in patients evaluated for rhabdomyolysis.
RESULTS: There were 673 patients with CK and uMb recorded on the same day. The uMb assay had a sensitivity of only 26.4% [95% confidence interval (CI): 23.1-29.7%] and specificity of 96.8% (95% CI: 95.5-98.1%) for the detection of severe rhabdomyolysis, defined as a CK >10 000 U/l. SMb and CK measured simultaneously in 83 patients were highly correlated (R(2) = 0.72 for log-transformed values), suggesting that the negative uMb test was not a result of the absence of sMb. In 241 patients who had CK, uMb and uH measured on the same day, the presence of 'moderate' or 'large' uH in the absence of haematuria, indicating presence of myoglobinuria, had a sensitivity of 81% (95% CI: 76-86%) for the detection of CK >10 000 U/l vs a sensitivity of 22% (95% CI: 17-27%) for the uMb assay.
CONCLUSIONS: The microconcentrator-based uMb assay has a poor and clinically inadequate sensitivity in the detection and diagnosis of rhabdomyolysis.

PMID 15280520  Nephrol Dial Transplant. 2004 Oct;19(10):2634-8. doi: 1・・・
著者: Helena Lappalainen, Eero Tiula, Lasse Uotila, Matti Mänttäri
雑誌名: Crit Care Med. 2002 Oct;30(10):2212-5.
Abstract/Text OBJECTIVE: Creatine kinase and myoglobin are markers of muscular damage in rhabdomyolysis. Whereas myoglobin is considered to be the principal compound causing tubular damage, serum creatine kinase level is presently guiding therapeutic interventions in clinical practice to prevent acute renal failure. Because differences in elimination kinetics of these two compounds may influence therapeutic decisions, we studied elimination kinetics of myoglobin and creatine kinase in patients with rhabdomyolysis.
DESIGN: Open, noncomparative study.
SETTING: Intensive and intermediary care units in a university hospital.
PATIENTS: A total of 13 consecutive patients with rhabdomyolysis whose baseline serum creatine kinase exceeded 5000 IU/L. Ten of 13 patients were treated with forced alkaline diuresis, and none were dialyzed.
RESULTS: Myoglobin had faster elimination kinetics than creatine kinase (p <.01), and the average times to reach the 50% level of initial values were 12 hrs for myoglobin and 42 hrs for creatine kinase. Elimination of myoglobin was not affected by glomerular filtration rate. Compared with creatinine clearance (mean, 102 mL/min), myoglobin clearance was low (mean, 3 mL/min), both in patients with preserved renal function (n = 11) and in those with acute renal failure (n = 2).
CONCLUSION: Serum myoglobin has faster elimination kinetics than creatine kinase in patients treated with forced alkaline diuresis for rhabdomyolysis. Considering the etiologic role of myoglobin, our data suggest that serum myoglobin level, rather than that of creatine kinase, should be used to guide therapy in patients with rhabdomyolysis.

PMID 12394946  Crit Care Med. 2002 Oct;30(10):2212-5.
著者: Y Wakabayashi, T Kikuno, T Ohwada, R Kikawada
雑誌名: Intensive Care Med. 1994;20(2):109-12.
Abstract/Text OBJECTIVE: Myoglobin kinetics of removal from the circulation were studied in patients following massive rhabdomyolysis, to see if myoglobin remains for long in the circulation in the anuric state and if myoglobin elimination was affected by therapeutic manipulation such as haemofiltration or haemodialysis.
DESIGN: Randomised and controlled study.
SETTING: Intensive care unit of a tertiary care teaching hospital.
PATIENTS: 26 patients of rhabdomyolysis whose serum myoglobin exceeded more than 500 nmol/l. Thirteen patients developed acute renal failure and underwent treatment with blood purification (Group HD). The remaining 13 patients did not require treatment with blood purification (control subjects, Group non-HD).
INTERVENTIONS: In patients of group HD, twelve were treated with haemofiltration and/or haemodialysis. One was treated with peritoneal dialysis. The patient of group non-HD were treated with fluid infusion alone.
MEASUREMENTS AND RESULTS: The serum concentrations of myoglobin were serially determined. The highest levels of myoglobin was 1641 +/- 484 nmol/l (mean +/- SEM) in the group non-HD and were 8957 +/- 2300 in the group HD. In the group non-HD, the blood myoglobin fell exponentially once myoglobin release into the circulation ceased. This was also noted in the group HD. The exponential decrease was observed even on the days when the patient passed little urine or treatment with blood purification was not performed.
CONCLUSION: In patients with massive myoglobinaemia, the blood myoglobin rapidly fell independent of renal function or any therapeutic manipulation. The results indicate that extrarenal factors played a major role in disposing circulating myoglobin in such patients.

PMID 8201089  Intensive Care Med. 1994;20(2):109-12.
著者: J Veenstra, W M Smit, R T Krediet, L Arisz
雑誌名: Nephrol Dial Transplant. 1994;9(6):637-41.
Abstract/Text The incidence, causes and complications of severe rhabdomyolysis (creatine phosphokinase (CK) > or = 5000 U/l) were studied during a 7-year study period in a large university hospital population. This condition was present in 0.074% of all admitted patients. The mortality in the study group (n = 93) was 32% and the incidence of acute renal failure (ARF) 51%. Ischaemia was the most frequent cause, and drugs, alcohol and/or coma were the second most common cause of severe rhabdomyolysis. Patients with rhabdomyolysis due to ischaemia were older, had ARF more often, and also had the highest mortality. Hyperkalaemia (potassium > or = 5.5 mmol/l) occurred in 13% of the patients, and all of them had or developed an impaired renal function. Hypocalcaemia (calcium < or = 2.00 mmol/l) was found in 41%. The incidence of ARF and electrolyte disturbances was higher in patients with CK levels exceeding 15,000 U/l. Mortality was significantly higher in patients with ARF. Plasma concentrations of potassium and calcium correlated better with the severity of renal failure than with the maximal height of plasma CK.

PMID 7970089  Nephrol Dial Transplant. 1994;9(6):637-41.
著者: Todd Ulmer
雑誌名: J Orthop Trauma. 2002 Sep;16(8):572-7.
Abstract/Text OBJECTIVE: To assess whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings.
DATA SOURCES: A MEDLINE search of the English literature from 1966 to 2001 was performed using "compartment syndromes" as the subject. A manual search of the bibliographies of retrieved articles and of major orthopaedic texts was also performed.
STUDY SELECTION AND EXTRACTION: Of 1,932 titles identified, 433 abstracts of potential relevance were reviewed, and 104 articles from relevant abstracts were examined in their entirety. Four studies met all eligibility criteria. Criteria for inclusion included the following: (a) target population, traumatic or iatrogenic tibia injuries; (b) diagnostic test, presence of data needed to calculate both the sensitivity and specificity of clinical findings; (c) outcome, the presence or absence of compartment syndrome; and (d) methodologic criteria, prospective study design.
DATA SYNTHESIS: The likelihood ratio form of Bayes' theorem was used to assess the discriminatory ability of the clinical findings as tests for the compartment syndrome.
CONCLUSIONS: There are limited data from which to define the usefulness of clinical findings for the diagnosis of compartment syndrome. Data from eligible studies suggest that the sensitivity of clinical findings for diagnosing compartment syndrome is low (13% to 19%). The positive predictive value of the clinical findings was 11% to 15%, and the specificity and negative predictive value were each 97% to 98%. These findings suggest that the clinical features of compartment syndrome of the lower leg are more useful by their absence in excluding the diagnosis than they are when present in confirming the diagnosis. Likelihood ratio calculations found that the probability of compartment syndrome with one clinical finding was approximately 25%, and the probability was 93% with 3 clinical findings present. However, these findings are based on limited information; because of the paucity of data available, the predictive value of the clinical findings for the diagnosis of compartment syndrome has yet to be defined.

PMID 12352566  J Orthop Trauma. 2002 Sep;16(8):572-7.
著者: Christian Vaillancourt, Ian Shrier, Alain Vandal, Markus Falk, Michel Rossignol, Alan Vernec, Dan Somogyi
雑誌名: CJEM. 2004 May;6(3):147-54.
Abstract/Text OBJECTIVES: Acute compartment syndrome (ACS) is a limb-threatening condition often first diagnosed by emergency physicians. Little is known about the rapidity with which permanent damage may occur. Our objective was to estimate the time to muscle necrosis in patients with ACS.
METHODS: This historical cohort analysis of all patients who had a fasciotomy for ACS was conducted in 4 large teaching hospitals. Diagnosis was confirmed clinically or by needle measurement of compartment pressure. Muscle necrosis was determined using pathology reports and surgeons' operative protocols. We used descriptive statistics and estimated tissue survival probability using the Vertex exchange method for interval-censored data.
RESULTS: Between 1989 and 1997 there were 76 cases of ACS. Most cases occurred in young men (median age 32) as a result of a traumatic incident (82%). Forty-nine percent (37/76) of all patients suffered some level of muscle necrosis, and 30% (11/37) of those with necrosis lost more than 25% of the muscle belly. Necrosis occurred in 2 of 4 cases in which the patient had been operated on within 3 hours of the injury, and our exploratory survival analysis estimates that 37% (95% confidence interval, 13%-51%) of all cases of ACS may develop muscle necrosis within 3 hours of the injury.
CONCLUSIONS: This is the largest cohort of ACS and the first clinical estimation of time to muscle necrosis ever published. Ischemia from ACS can cause muscle necrosis before the 3-hour period post-trauma that is traditionally considered safe. Further research to identify risk factors associated with the development of early necrosis is necessary.

PMID 17433166  CJEM. 2004 May;6(3):147-54.
著者: E Homsi, M F Barreiro, J M Orlando, E M Higa
雑誌名: Ren Fail. 1997 Mar;19(2):283-8.
Abstract/Text Patients that develop rhabdomyolysis of different causes are at high risk of acute renal failure. Efforts to minimize this risk include volume repletion, treatment with mannitol, and urinary alkalinization as soon as possible after muscle injury. This is a retrospective analysis (from January 1, 1992, to December 31, 1995) of therapeutic response to prophylactic treatment in patients with rhabdomyolysis admitted to an intensive care unit (ICU). The diagnosis of rhabdomyolysis was based on creatinine kinase (CK) level (> 500 Ui/L) and the criteria for prophylaxis were: time elapsed between muscle injury to ICU admission < 48 h and serum creatinine < 3 mg/dL. Fifteen patients were treated with the association of saline, mannitol, and sodium bicarbonate (S + M + B group) and 9 patients received only saline (S group). Serum creatinine at admission was similar in both groups: 1.6 +/- 0.6 mg/dL in the S + M + B group and 1.5 +/- 0.6 mg/dL in the S group (p > 0.05). Maximum serum CK measured was 3351 +/- 1693 IU/L in the S + M + B group and 1747 +/- 2345 IU/L in the S group (p < 0.05). However the measurement of CK was earlier in S + M + B patients (1.7 vs 2.7 days after rhabdomyolysis). APACHE II scores were 16.9 +/- 7.4 and 13.4 +/- 4.9 in the S + M + MB and S groups, respectively (p > 0.05). Despite the treatment protocol the serum levels of creatinine had similar behavior and reached normal levels in all patients in 2 or 3 days. The saline infusion during the first 60 h on the ICU was 206 mL/h in the S group and 204 mL/h in S + M + B (p > 0.05). Mannitol dose was 56 g/day, and bicarbonate 225 mEq/day during 4.7 days. Our data show that progression to established renal failure can be totally avoided with prophylactic treatment, and that once appropriate saline expansion is provided, the association of mannitol and bicarbonate seems to be unnecessary.

PMID 9101605  Ren Fail. 1997 Mar;19(2):283-8.
著者: Xavier Bosch, Esteban Poch, Josep M Grau
雑誌名: N Engl J Med. 2009 Jul 2;361(1):62-72. doi: 10.1056/NEJMra0801327.
Abstract/Text
PMID 19571284  N Engl J Med. 2009 Jul 2;361(1):62-72. doi: 10.1056/NEJ・・・
著者: Kwok M Ho, David J Sheridan
雑誌名: BMJ. 2006 Aug 26;333(7565):420. doi: 10.1136/bmj.38902.605347.7C. Epub 2006 Jul 21.
Abstract/Text OBJECTIVE: To investigate the potential beneficial and adverse effects of frusemide to prevent or treat acute renal failure in adults.
DESIGN: Meta-analysis of randomised controlled trials.
DATA SOURCES: Cochrane controlled trials register (2005 issue 4), Embase, and Medline (1966 to 1 February 2006), without language restrictions.
REVIEW METHODS: Two reviewers checked the quality of the studies and independently extracted data.
RESULTS: Nine randomised controlled trials totalling 849 patients with or at risk of acute renal failure were included. Outcome measures not significantly different after frusemide treatment were in-hospital mortality (relative risk 1.11, 95% confidence interval 0.92 to 1.33), risk for requiring renal replacement therapy or dialysis (0.99, 0.80 to 1.22), number of dialysis sessions required (weight mean difference--0.48 sessions, -1.45 to 0.50), and proportion of patients with persistent oliguria (urine output < 500 ml/day: 0.54, 0.18 to 1.61). Stratifying studies that used frusemide to prevent or treat acute renal failure did not change the results on mortality (relative risk ratio 2.10, 95% confidence interval 0.67 to 6.63) and the risk for requiring dialysis (4.12, 0.46 to 37.2). Evidence suggested an increased risk of temporary deafness and tinnitus in patients treated with high doses of frusemide (relative risk 3.97, 95% confidence interval 1.00 to 15.78).
CONCLUSIONS: Frusemide is not associated with any significant clinical benefits in the prevention and treatment of acute renal failure in adults. High doses may be associated with an increased risk of ototoxicity.

PMID 16861256  BMJ. 2006 Aug 26;333(7565):420. doi: 10.1136/bmj.38902.・・・
著者: Sean M Bagshaw, Anthony Delaney, Michael Haase, William A Ghali, Rinaldo Bellomo
雑誌名: Crit Care Resusc. 2007 Mar;9(1):60-8.
Abstract/Text BACKGROUND: Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF.
METHODS: Studies were identified by search of MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register, and review of proceedings from selected scientific meetings and clinical trial registries, and bibliographies of retrieved citations. We selected randomised controlled trials (RCTs) comparing loop diuretics with control in patients with ARF. Data were extracted in duplicate by two independent reviewers on study characteristics, quality and outcomes. Primary outcomes were mortality, need for renal replacement therapy (RRT) and renal recovery. Secondary outcomes were change to urine output, serum potassium level and acid-base status, duration of ARF or RRT, length of hospital stay and toxicity.
RESULTS: Of 62 studies reviewed, five RCTs, enrolling 555 patients, were eligible and analysed. These trials enrolled a mix of patients, but only two included critically ill patients. Overall trial quality was low. There was no statistical difference in mortality (odds ratio [OR], 1.28; 95% CI, 0.89-1.84; P=0.18) or renal recovery (OR, 0.88; 95% CI, 0.59-1.31; P=0.5) with use of loop diuretics compared with control. However, loop diuretics were associated with a shorter duration of RRT (weighted mean difference, ?1.4 days; 95% CI, ?0.2 to ?2.3 days; P=0.02), shorter time to spontaneous decline in serum creatinine level (weighted mean difference, ?2.1 days; 95% CI, ?0.4 to ?3.7 days; P=0.01) and a greater increase in urine output from baseline (OR, 2.6; 95% CI, 1.4-4.9; P=0.004). Insufficient data were available on acid-base status, hospital length of stay or health costs. Four studies reported toxicity, most commonly transient tinnitus and deafness.
CONCLUSIONS: Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.

PMID 17352669  Crit Care Resusc. 2007 Mar;9(1):60-8.
著者: Sriram Sampath, John L Moran, Petra L Graham, Sue Rockliff, Andrew D Bersten, Keith R Abrams
雑誌名: Crit Care Med. 2007 Nov;35(11):2516-24.
Abstract/Text OBJECTIVE: To quantify the therapeutic efficacy of loop diuretics in acute renal failure using Bayesian evidence synthesis, because despite widespread use, the role of diuretics is controversial.
DATA SOURCE: Randomized controlled trials or nonrandomized studies, 1966 to January 2007, identified from MEDLINE and EMBASE databases and manual bibliographic search.
STUDY SELECTION: Studies with assessable predefined end points, exclusive of those pertaining to acute renal failure prophylaxis or chronic renal failure.
DATA EXTRACTION: Data extraction was performed jointly by the first two authors; independent study assessment was via standard checklist, unblinded.
DATA SYNTHESIS: The primary outcome was mortality; secondary outcomes were time to renal function normalization and total number of dialyses. Bayesian hierarchical random effects estimates of treatment effects were determined as risk ratio for mortality, incidence rate ratio for dialysis number, and mean difference for continuous measures. Bayesian outcome probabilities were calculated as probability (P) that risk ratio or incidence rate ratio of loop diuretics >1 and probability that mean difference >0. Five randomized controlled trials and eight nonrandomized studies were identified. Loop diuretics were not associated with decreased mortality in either randomized controlled trials or nonrandomized studies: overall risk ratio 1.10; 95% credible interval 0.85, 1.42; P(risk ratio >1) > 83.8%. The oliguric period was decreased by loop diuretics: overall mean difference -7.70 days; 95% credible interval -12.51, -2.08; P (mean difference >0) = 0.7%. Although the dialysis rate credible interval, loop diuretics vs. control, spanned unity (incidence rate ratio 0.71; 95% credible interval 0.47, 1.06), the probability that the incidence rate ratio exceeded unity indicated a substantial benefit: P (incidence rate ratio >1 = 4.1%. Uremic duration was not substantially different, loop diuretics vs. control: overall mean difference -1.54 days; 95% credible interval -5.62, 2.46; P [mean difference >0] = 17.8%).
CONCLUSIONS: Loop diuretics were not associated with improved survival benefit in acute renal failure, despite reduction in oliguric period and high probability of a significant reduction in dialysis numbers. Further studies to clarify this dichotomy appear mandated.

PMID 18084840  Crit Care Med. 2007 Nov;35(11):2516-24.
著者: Ravindra L Mehta, Maria T Pascual, Sharon Soroko, Glenn M Chertow, PICARD Study Group
雑誌名: JAMA. 2002 Nov 27;288(20):2547-53.
Abstract/Text CONTEXT: Acute renal failure is associated with high mortality and morbidity. Diuretic agents continue to be used in this setting despite a lack of evidence supporting their benefit.
OBJECTIVE: To determine whether the use of diuretics is associated with adverse or favorable outcomes in critically ill patients with acute renal failure.
DESIGN: Cohort study conducted from October 1989 to September 1995.
PATIENTS AND SETTING: A total of 552 patients with acute renal failure in intensive care units at 4 academic medical centers affiliated with the University of California. Patients were categorized by the use of diuretics on the day of nephrology consultation and, in companion analyses, by diuretic use at any time during the first week following consultation.
MAIN OUTCOME MEASURES: All-cause hospital mortality, nonrecovery of renal function, and the combined outcome of death or nonrecovery.
RESULTS: Diuretics were used in 326 patients (59%) at the time of nephrology consultation. Patients treated with diuretics on or before the day of consultation were older and more likely to have a history of congestive heart failure, nephrotoxic (rather than ischemic or multifactorial) origin of acute renal failure, acute respiratory failure, and lower serum urea nitrogen concentrations. With adjustment for relevant covariates and propensity scores, diuretic use was associated with a significant increase in the risk of death or nonrecovery of renal function (odds ratio, 1.77; 95% confidence interval, 1.14-2.76). The risk was magnified (odds ratio, 3.12; 95% confidence interval, 1.73-5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to diuretics.
CONCLUSIONS: The use of diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function. Although observational data prohibit causal inference, it is unlikely that diuretics afford any material benefit in this clinical setting. In the absence of compelling contradictory data from a randomized, blinded clinical trial, the widespread use of diuretics in critically ill patients with acute renal failure should be discouraged.

PMID 12444861  JAMA. 2002 Nov 27;288(20):2547-53.
著者: Gearoid M McMahon, Xiaoxi Zeng, Sushrut S Waikar
雑誌名: JAMA Intern Med. 2013 Oct 28;173(19):1821-8. doi: 10.1001/jamainternmed.2013.9774.
Abstract/Text IMPORTANCE: Rhabdomyolysis ranges in severity from asymptomatic elevations in creatine phosphokinase levels to a life-threatening disorder characterized by severe acute kidney injury requiring hemodialysis or continuous renal replacement therapy (RRT).
OBJECTIVE: To develop a risk prediction tool to identify patients at greatest risk of RRT or in-hospital mortality.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 2371 patients admitted between January 1, 2000, and March 31, 2011, to 2 large teaching hospitals in Boston, Massachusetts, with creatine phosphokinase levels in excess of 5000 U/L within 3 days of admission. The derivation cohort consisted of 1397 patients from Massachusetts General Hospital, and the validation cohort comprised 974 patients from Brigham and Women's Hospital.
MAIN OUTCOMES AND MEASURES: The composite of RRT or in-hospital mortality.
RESULTS: The causes and outcomes of rhabdomyolysis were similar between the derivation and validation cohorts. In total, the composite outcome occurred in 19.0% of patients (8.0% required RRT and 14.1% died during hospitalization). The highest rates of the composite outcome were from compartment syndrome (41.2%), sepsis (39.3%), and following cardiac arrest (58.5%). The lowest rates were from myositis (1.7%), exercise (3.2%), and seizures (6.0%). The independent predictors of the composite outcome were age, female sex, cause of rhabdomyolysis, and values of initial creatinine, creatine phosphokinase, phosphate, calcium, and bicarbonate. We developed a risk-prediction score from these variables in the derivation cohort and subsequently applied it in the validation cohort. The C statistic for the prediction model was 0.82 (95% CI, 0.80-0.85) in the derivation cohort and 0.83 (0.80-0.86) in the validation cohort. The Hosmer-Lemeshow P values were .14 and .28, respectively. In the validation cohort, among the patients with the lowest risk score (<5), 2.3% died or needed RRT. Among the patients with the highest risk score (>10), 61.2% died or needed RRT.
CONCLUSIONS AND RELEVANCE: Outcomes from rhabdomyolysis vary widely depending on the clinical context. The risk of RRT or in-hospital mortality in patients with rhabdomyolysis can be estimated using commonly available demographic, clinical, and laboratory variables on admission.

PMID 24000014  JAMA Intern Med. 2013 Oct 28;173(19):1821-8. doi: 10.10・・・
著者: Young Soon Cho, Hoon Lim, Seung Ho Kim
雑誌名: Emerg Med J. 2007 Apr;24(4):276-80. doi: 10.1136/emj.2006.043265.
Abstract/Text OBJECTIVE: To compare the effectiveness and side effects of lactated Ringer's solution (LR) and 0.9% saline (NS) in the treatment of rhabdomyolysis induced by doxylamine intoxication.
METHODS: In this 15-month-long prospective randomised single-blind study, after excluding 8 patients among 97 doxylamine-intoxicated patients, 28 (31%) patients were found to have developed rhabdomyolysis and were randomly allocated to NS group (n = 15) or LR group (n = 13).
RESULTS: After 12 h of aggressive hydration (400 ml/h), urine/serum pH was found to be significantly higher in the LR group, and serum Na+/Cl- levels to be significantly higher in the NS group. There were no significant differences in serum K+ level and in the time taken for creatine kinase normalisation. The amount of sodium bicarbonate administered and the frequency administration of diuretics was significantly higher in the NS group. Unlike the NS group, the LR group needed little supplemental sodium bicarbonate and did not develop metabolic acidosis.
CONCLUSION: LR is more useful than NS in the treatment of rhabdomyolysis induced by doxylamine intoxication.

PMID 17384382  Emerg Med J. 2007 Apr;24(4):276-80. doi: 10.1136/emj.20・・・
著者: Xiaoxi Zeng, Ling Zhang, Taixiang Wu, Ping Fu
雑誌名: Cochrane Database Syst Rev. 2014 Jun 15;(6):CD008566. doi: 10.1002/14651858.CD008566.pub2. Epub 2014 Jun 15.
Abstract/Text BACKGROUND: Rhabdomyolysis is a condition that is characterised by the breakdown of skeletal muscle tissue and leakage of intracellular myocyte contents into circulating blood. Rhabdomyolysis can lead to acute kidney injury (AKI) and is a potentially life-threatening condition. Studies have indicated that continuous renal replacement therapy (CRRT) may provide benefits for people with rhabdomyolysis by removing potentially damaging myoglobin and stabilising haemodynamic and metabolic status.
OBJECTIVES: We aimed to: i) assess the efficacy of CRRT in removing myoglobin; ii) investigate the influence of CRRT on mortality and kidney-related outcomes; and iii) evaluate the safety of CRRT for the treatment of people with rhabdomyolysis.
SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 6 January 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched China National Knowledge Infrastructure (from 1 January 1979 to 16 April 2013) and the Chinese Clinical Trials Register (to 16 April 2013).
SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs that investigated clinical outcomes of CRRT for people with rhabdomyolysis were included.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion and extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool.
MAIN RESULTS: Of the three included studies (101 participants), one evaluated continuous arteriovenous haemodialysis and two investigated continuous venovenous haemofiltration; all included conventional therapy as control.We found significant decreases in myoglobin in patients among whom CRRT therapy was initiated on days four, eight, and 10 (day 4: MD -11.00 (μg/L), 95% CI -20.65 to -1.35; Day 8: MD -23.00 (μg/L), 95% CI -30.92 to -15.08; day 10: MD -341.87 (μg/L), 95% CI -626.15 to -57.59) compared with those who underwent conventional therapy.Although CRRT was associated with improved serum creatinine, blood urea nitrogen, and potassium levels; reduced duration of the oliguria phase; and was associated with reduced time in hospital, no significant differences were found in mortality rates compared with conventional therapy (RR 0.17, 95% CI 0.02 to 1.37). The included studies did not report on long-term outcomes or prevention of AKI.Overall, we found that study quality was suboptimal: blinding and randomisation allocation were not reported by any of the included studies, leading to the possibility of selection, performance and detection bias.
AUTHORS' CONCLUSIONS: Although CRRT may provide some benefits for people with rhabdomyolysis, the poor methodological quality of the included studies and lack of data relating to clinically important outcomes limited our findings about the effectiveness of CRRT for people with rhabdomyolysis.There was insufficient evidence to discern any likely benefits of CRRT over conventional therapy for people with rhabdomyolysis and prevention of rhabdomyolysis-induced AKI.

PMID 24929959  Cochrane Database Syst Rev. 2014 Jun 15;(6):CD008566. d・・・

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