Exertional rhabdomyolysis-induced “normokalemic” severe acute kidney injury. A case report and a brief literature review

Year 2023, , 100 - 104, 29.07.2023

Alper Tuna Güven , Rüya Özelsancak

https://doi.org/10.56016/dahudermj.1312590

Abstract

Rhabdomyolysis is the breakdown of the muscle cells with the resultant leakage of intracellular components. Hyperkalemia and hyperphosphatemia may occur during the disease course, as well as acute kidney injury due to blockade of the tubules by myoglobin released from the muscle cells. Electrolyte disturbances are generally more severe than acute kidney injuries. We would like to report a patient who was diagnosed with exertional rhabdomyolysis-induced acute kidney injury due to vigorous swimming and who required hemodialysis but lacked hyperkalemia. The discrepancy between the severe acute kidney injury and lack of hyperkalemia was remarkable. A brief literature search also revealed several patient reports with hypo- and normokalemia despite experiencing acute kidney injury. Pathophysiologic explanations for this discrepancy include exercise-induced increased kaliuresis and intracellular shifting of potassium.

Keywords

Rhabdomyolysis, acute kidney injury, potassium, exercise, dialysis

References

• McMahon GM, Zeng X, Waikar SS. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013;173(19):1821-1828. doi:10.1001/jamainternmed.2013.9774
• Lordon RE, Burton JR. Post-traumatic renal failure in military personnel in Southeast Asia. Experience at Clark USAF hospital, Republic of the Philippines. Am J Med. 1972;53(2):137-147. doi:10.1016/0002-9343(72)90124-6
• Poortmans JR. Exercise and renal function. Sports Med. 1984;1(2):125-153. doi:10.2165/00007256-198401020-00003
• Wang AY, Li PK, Lui SF, Lai KN. Renal failure and heatstroke. Ren Fail. 1995;17(2):171-179. doi:10.3109/08860229509026254
• Aizawa H, Morita K, Minami H, Sasaki N, Tobise K. Exertional rhabdomyolysis as a result of strenuous military training. J Neurol Sci. 1995;132(2):239-240. doi:10.1016/0022-510x(95)00144-q
• Pereira F, Moraes R, Bavel D, Lorenzo AR, Tibirica E. Exertional Rhabdomyolysis after Military Training Paralleled by Systemic Microvascular Dysfunction and Plasma Cytokine Increase: A Case Report. Arq Bras Cardiol. 2019;113(2):294-298. Published 2019 Sep 2. doi:10.5935/abc.20190165
• Stahl CE, Borlongan CV, Szerlip M, Szerlip H. No pain, no gain--exercise-induced rhabdomyolysis associated with the performance enhancer herbal supplement ephedra. Med Sci Monit. 2006;12(9):CS81-CS84.
• Tseng GS, Hsieh CY, Hsu CT, Lin JC, Chan JS. Myopericarditis and exertional rhabdomyolysis following an influenza A (H3N2) infection. BMC Infect Dis. 2013;13:283. Published 2013 Jun 21. doi:10.1186/1471-2334-13-283
• Anzalone ML, Green VS, Buja M, Sanchez LA, Harrykissoon RI, Eichner ER. Sickle cell trait and fatal rhabdomyolysis in football training: a case study. Med Sci Sports Exerc. 2010;42(1):3-7. doi:10.1249/MSS.0b013e3181ae0700
• Aquilina A, Pirotta T, Aquilina A. Acute liver failure and hepatic encephalopathy in exertional heat stroke. BMJ Case Rep. 2018;2018:bcr2018224808. Published 2018 Jul 30. doi:10.1136/bcr-2018-224808
• Rhidian R. Running a risk? Sport supplement toxicity with ephedrine in an amateur marathon runner, with subsequent rhabdomyolysis. BMJ Case Rep. 2011;2011:bcr1120115093. Published 2011 Dec 13. doi:10.1136/bcr.11.2011.5093
• Hannabass K, Olsen KR. Fat burn X: burning more than fat. BMJ Case Rep. 2016;2016:bcr2015213374. Published 2016 Jan 25. doi:10.1136/bcr-2015-213374
• Braseth NR, Allison EJ Jr, Gough JE. Exertional rhabdomyolysis in a body builder abusing anabolic androgenic steroids. Eur J Emerg Med. 2001;8(2):155-157. doi:10.1097/00063110-200106000-00015
• Bruso JR, Hoffman MD, Rogers IR, Lee L, Towle G, Hew-Butler T. Rhabdomyolysis and hyponatremia: a cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness Environ Med. 2010;21(4):303-308. doi:10.1016/j.wem.2010.06.012
• Hart LE, Egier BP, Shimizu AG, Tandan PJ, Sutton JR. Exertional heat stroke: the runner’s nemesis. Can Med Assoc J. 1980;122(10):1144-1150.
• Chakraborty S, Sural S. A young patient of hereditary renal hypouricaemia presenting with exercise-induced rhabdomyolysis and acute kidney injury. Ann Clin Biochem. 2013;50(Pt 3):271-273. doi:10.1258/acb.2012.012017
• Al Badi A, Al Rasbi S, Alalawi AM. Exercise-Induced Rhabdomyolysis: A Case Report and Literature Review. Cureus. 2020;12(8):e10037. Published 2020 Aug 26. doi:10.7759/cureus.10037
• Daher Ede F, Silva Júnior GB, Brunetta DM, Pontes LB, Bezerra GP. Rhabdomyolysis and acute renal failure after strenuous exercise and alcohol abuse: case report and literature review. Sao Paulo Med J. 2005;123(1):33-37. doi:10.1590/s1516-31802005000100008
• Ellis C, Cuthill J, Hew-Butler T, George SM, Rosner MH. Case report: exercise-associated hyponatremia with rhabdomyolysis during endurance exercise. Phys Sportsmed. 2009;37(1):126-132. doi:10.3810/psm.2009.04.1693
• Ferster K, Eichner ER. Exertional sickling deaths in Army recruits with sickle cell trait. Mil Med. 2012;177(1):56-59. doi:10.7205/milmed-d-11-00106
• Hamilton RW, Gardner LB, Penn AS, Goldberg M. Acute tubular necrosis caused by exercise-induced myoglobinuria. Ann Intern Med. 1972;77(1):77-82. doi:10.7326/0003-4819-77-1-77
• Hassanein T, Perper JA, Tepperman L, Starzl TE, Van Thiel DH. Liver failure occurring as a component of exertional heatstroke. Gastroenterology. 1991;100(5 Pt 1):1442-1447.
• Nelson SR, Phillips AO, Hendry BM. Hypothyroidism and rhabdomyolysis in a marathon runner. Nephrol Dial Transplant. 1993;8(4):375-376.
• Kahanov L, Eberman LE, Wasik M, Alvey T. Exertional rhabdomyolysis in a collegiate american football player after preventive cold-water immersion: a case report. J Athl Train. 2012;47(2):228-232. doi:10.4085/1062-6050-47.2.228
• Kerle KK, Nishimura KD. Exertional collapse and sudden death associated with sickle cell trait. Mil Med. 1996;161(12):766-767.
• Kim HR, Kim SH, Oh DJ. Rhabdomyolysis after a regular exercise session in a patient with Graves’ disease. Nephrology (Carlton). 2012;17(3):307-308. doi:10.1111/j.1440-1797.2011.01528.x
• Kuklo TR, Tis JE, Moores LK, Schaefer RA. Fatal rhabdomyolysis with bilateral gluteal, thigh, and leg compartment syndrome after the Army Physical Fitness Test. A case report. Am J Sports Med. 2000;28(1):112-116. doi:10.1177/03635465000280010401
• Pattison ME, Logan JL, Lee SM, Ogden DA. Exertional heat stroke and acute renal failure in a young woman. Am J Kidney Dis. 1988;11(2):184-187. doi:10.1016/s0272-6386(88)80210-5
• Pearcey GE, Bradbury-Squires DJ, Power KE, Behm DG, Button DC. Exertional rhabdomyolysis in an acutely detrained athlete/exercise physiology professor. Clin J Sport Med. 2013;23(6):496-498. doi:10.1097/JSM.0b013e318291d39e
• Shelmadine BD, Baltensperger A, Wilson RL, Bowden RG. Rhabdomyolysis and acute renal failure in a sickle cell trait athlete: a case study. Clin J Sport Med. 2013;23(3):235-237. doi:10.1097/JSM.0b013e3182625a37
• Sherner JH, Yuan CM. A 20-year-old army private with leg pain, fever, and collapse during a forced road march. Mil Med. 2002;167(4):363-366.
• Steidl KE, Darko W, Probst LA, Noviasky JA, Nasser S. Rhabdomyolysis associated with phentermine. Am J Health Syst Pharm. 2010;67(22):1929-1932. doi:10.2146/ajhp090395
• Tietjen DP, Guzzi LM. Exertional rhabdomyolysis and acute renal failure following the Army Physical Fitness Test. Mil Med. 1989;154(1):23-25.
• Unnikrishnan D, Satish B. Exertion-induced rhabdomyolysis in a patient on statin therapy. Nephrol Dial Transplant. 2005;20(1):244. doi:10.1093/ndt/gfh578
• West H. Rhabdomyolysis associated with compartment syndrome resulting in acute renal failure. Eur J Emerg Med. 2007;14(6):368-370. doi:10.1097/MEJ.0b013e32823a3c8b
• Zimmerman J, Granatir R, Mummert K, Cioffi R. Sickle crisis precipitated by exercise rhabdomyolysis in a patient with sickle cell trait: case report. Mil Med. 1974;139(4):313-315.