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高CK血症

著者: 前野貴美 筑波大学 総合診療科

監修: 前野哲博 筑波大学医学医療系 地域医療教育学

著者校正/監修レビュー済:2021/04/28

概要・推奨   

  1. ミオパチー(骨格筋疾患)が疑われる患者では、CK、AST、LDH、アルドラーゼの測定が勧められる
  1. 炎症性ミオパチー(皮膚筋炎・多発性筋炎)では、ほとんどすべての患者で経過中に筋原性酵素の上昇が認められる。
  1. 横紋筋融解症の入院患者の検討では、原因の約半数を薬剤など外因性の毒素が占めていた。
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:
前野貴美 : 特に申告事項無し[2021年]
監修:前野哲博 : 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、感染性ミオパチーについて加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. CK(Creatine kinase:クレアチンキナーゼ)はCPK(Creatine phosphokinase:クレアチンホスホキナーゼ)とも呼ばれ、筋肉や脳に多量に存在し、エネルギー代謝に関与する重要な酵素である[1][2]
  1. 男性は女性よりも高値、幼児は成人の約2倍の高値であり、加齢とともに低下して成人値となる。これらは身体活動性のためである[1][2]
問診・診察のポイント  
  1. CK上昇をみた場合、心疾患、骨格筋疾患などの可能性を考慮し、問診・診察を行う。

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文献 

著者: T J Bohlmeyer, A H Wu, M B Perryman
雑誌名: Rheum Dis Clin North Am. 1994 Nov;20(4):845-56.
Abstract/Text Plasma CK concentrations have been widely used as the primary muscle enzyme marker for diagnosis and progression of myositis. Recently, total CK and CK-MB serum concentrations have been compared to, and used in conjunction with, serum concentrations of aspartate aminotransferase in diagnosis of myositis. The algorithmic use of CK, AST, and aldolase plasma concentrations to diagnose and categorize patients with myopathy may be a useful method of diagnosing specific muscle disease without invasive procedures. CAIII, as a specific marker for skeletal muscle damage, may replace CK as the enzyme of choice in diagnosis and progression of myositis and other muscle disease. Additional studies are required to determine the usefulness of carbonic anhydrase for the diagnosis and assessment of myositis.

PMID 7855325  Rheum Dis Clin North Am. 1994 Nov;20(4):845-56.
著者: G Ramírez, R A Asherson, M A Khamashta, R Cervera, D D'Cruz, G R Hughes
雑誌名: Semin Arthritis Rheum. 1990 Oct;20(2):114-20.
Abstract/Text A retrospective study of 25 patients with polymyositis-dermatomyositis (PM-DM) is analyzed with special attention to the effects of therapy and follow-up. All patients (100%) complained of muscle weakness and 68% of these demonstrated typical skin changes of DM. All patients, except 2, received corticosteroids at the onset of the disease, 23 were treated with azathioprine, 7 received cyclophosphamide, 4 methotrexate, and 1 had total body irradiation. Among the patients adequately treated with azathioprine, 75% had a good response, but 5 patients did not improve. Cyclophosphamide was used subsequently in 2, with a satisfactory response in 1. Another patient had a striking response to oral methotrexate, and total body irradiation helped to improve another patient. Although high dose corticosteroids were the preferred starting medication for the treatment of PM-DM, it is important to detect those patients who do not respond adequately and/or develop side effects. In these circumstances, the prompt use of immunosuppressive agents appears justified.

PMID 2251506  Semin Arthritis Rheum. 1990 Oct;20(2):114-20.
著者: P M Tiidus, C D Ianuzzo
雑誌名: Med Sci Sports Exerc. 1983;15(6):461-5.
Abstract/Text The purposes of this study were to: 1) determine the time course of changes in serum enzyme activities and muscular soreness following muscular exercise, 2) quantify the relative amounts and importance of intensity and duration of muscular exercise in inducing elevated serum enzyme activities and muscular soreness in untrained individuals, and 3) determine the correlation between magnitude of soreness sensation and level of post-exercise serum enzyme activity. It was determined that the highest serum enzyme activities and muscular soreness sensation occurred 8-24 h and 48 h post-exercise, respectively. Intensity and duration of exercise were varied by adjusting the percent 10-repetition maximum (% 10RM) and number of contractions (NR) performed. Increasing intensity and duration of exercise resulted in corresponding increases in serum enzyme activities and muscular soreness. High-intensity, short-duration exercise (80% 10RM, 170 NR) resulted in greater serum enzyme activities and muscular soreness than long-duration, low-intensity exercise (30% 10RM, 545 NR). Most subjects experiencing high levels of muscular soreness were unable to lift resistances of 90% 1RM, 48 h post-exercise. These findings indicate that a positive relationship exists among exercise performed, serum enzyme activity 24 h post-exercise, and muscular soreness. Increased intensity and duration of exercise produced increased serum enzyme activities and muscular soreness, with intensity having the more pronounced effect.

PMID 6656554  Med Sci Sports Exerc. 1983;15(6):461-5.
著者: Siamak Moghadam-Kia, Chester V Oddis, Rohit Aggarwal
雑誌名: Cleve Clin J Med. 2016 Jan;83(1):37-42. doi: 10.3949/ccjm.83a.14120.
Abstract/Text How to manage a patient who has an elevated serum creatine kinase (CK) level but no or insignificant muscle-related signs and symptoms is a clinical conundrum. The authors provide a systematic approach, including repeat testing after a period of rest, defining higher thresholds over which pursuing a diagnosis is worthwhile, and evaluating for a variety of nonneuromuscular causes. They also outline a workup for neuromuscular causes.

Copyright © 2016 Cleveland Clinic.
PMID 26760521  Cleve Clin J Med. 2016 Jan;83(1):37-42. doi: 10.3949/cc・・・
著者: Giorgia Melli, Vinay Chaudhry, David R Cornblath
雑誌名: Medicine (Baltimore). 2005 Nov;84(6):377-85.
Abstract/Text Rhabdomyolysis is a common and potentially lethal clinical syndrome that results from acute muscle fiber necrosis with leakage of muscle constituents into blood. Myoglobinuria is the most significant consequence, leading to acute renal failure (ARF) in 15%-33% of patients with rhabdomyolysis. Rhabdomyolysis occurs from inherited diseases, toxins, muscle compression or overexertion, or inflammatory processes, among other disorders. In some cases, no cause is found. We describe 475 patients from the Johns Hopkins Hospital inpatient records between January 1993 and December 2001 for the following discharge diagnosis codes: myoglobinuria, rhabdomyolysis, myopathy, toxic myopathy, malignant hyperthermia, neuroleptic malignant syndrome, and polymyositis. Of 1362 patients, 475 patients with an acute neuromuscular illness with serum creatine kinase (CK) more than 5 times the upper limit of normal (>975 IU/L) were included. Patients with recent myocardial infarction or stroke were excluded. The etiology was assigned by chart review. For all, the highest values of serum CK, serum creatinine and urine myoglobin, hemoglobin, and red blood cells were recorded. Forty-one patients had muscle biopsy within at least 2 months from the onset of rhabdomyolysis.Of the 475 patients, 151 were female and 324 were male (median age, 47 yr; range, 4-95 yr). Exogenous toxins were the most common cause of rhabdomyolysis, with illicit drugs, alcohol, and prescribed drugs responsible for 46%. Among the medical drugs, antipsychotics, statins, zidovudine, colchicine, selective serotonin reuptake inhibitors, and lithium were the most frequently involved. In 60% of all cases, multiple factors were present. In 11% of all cases, rhabdomyolysis was recurrent. Underlying myopathy or muscle metabolic defects were responsible for 10% of cases, in which there was a high percentage of recurrence, only 1 etiologic factor, and a low incidence of ARF. In 7%, no cause was found. ARF was present in 218 (46%) patients, and 16 died (3.4%). A linear correlation was found between CK and creatinine and between multiple factors and ARF, but there was no correlation between ARF and death or between multiple factors and death. Urine myoglobin detected by dipstick/ultrafiltration was positive in only 19%. Toxins are the most frequent cause of rhabdomyolysis, but in most cases more than 1 etiologic factor was present. Patients using illicit drugs or on prescribed polytherapy are at risk for rhabdomyolysis. The absence of urine myoglobin, by qualitative assay, does not exclude rhabdomyolysis. With appropriate care, death is rare.

PMID 16267412  Medicine (Baltimore). 2005 Nov;84(6):377-85.

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