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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1994  |  Volume : 5  |  Issue : 1  |  Page : 17-22
Acute Renal Failure due to Rhabdomyolysis Following Human Stampede


1 Jeddah Kidney Center, King Fahd Hospital, Jeddah, Saudi Arabia
2 Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
3 A1-Noor Hospital, Makkah, Saudi Arabia

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   Abstract 

Acute renal failure (ARF) following rhabdomyolysis is a well known entity. In this paper, we present an unusual cause for trauma that resulted in rhabdomyolysis associated with renal failure. Rhabdomyolysis resulted from human stampede that occurred in a mountain tunnel on the occasion of The Pilgrimage to Makkah in 1990. To the best of our knowledge, human stampede as a cause of rhabdomyolysis has not been reported in the literature. A total of eight patients were referred to our center. Laboratory investigations revealed rhabdomyolysis as well as evidence of moderate to severe renal impairment in all patients. They were treated with forced alkaline diuresis, but three required hemodialysis. All patients recovered. Treatment with forced alkaline diuresis was found to be useful in the treatment of these patients and instituting such treatment is worthwhile even in those cases where renal failure is established.

Keywords: Acute Renal Failure, Rhabdomyolysis, Human Stampede, Dialysis, Compartmental Syndrome, Forced Alkaline Diuresis.

How to cite this article:
Sheikh IA, Shaheen FA, El-Aqeil NA, Al-Khader A, Karsuwa S. Acute Renal Failure due to Rhabdomyolysis Following Human Stampede. Saudi J Kidney Dis Transpl 1994;5:17-22

How to cite this URL:
Sheikh IA, Shaheen FA, El-Aqeil NA, Al-Khader A, Karsuwa S. Acute Renal Failure due to Rhabdomyolysis Following Human Stampede. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Jun 6];5:17-22. Available from: http://www.sjkdt.org/text.asp?1994/5/1/17/41356

   Introduction Top


Rhabdomyolysis results from several etiological factors such as alcoholism [1] , seizures [2] , drug ingestion [1],[3] , prolonged immobilization [4] , direct trauma [5] , exposure to cold [6] , influenza like illnesses [7] , polymyositis [8] , respiratory disorders [9] , sepsis [10] and burns [11] . It may also be idiopathic [12] . In this paper, we report an unusual cause for trauma which resulted in rhabdomyolysis as well as our experience in treating this condition and the associated acute renal failure (ARF)


   Case History Top


During The Pilgrimage to Makkah in June the summer of 1990, sudden panic erupted among the people who were passing through a mountain tunnel made as a shortcut between the holy City of Makkah and the camp city of Muna. This was caused by over crowding in the tunnel. The ensuing sense of suffocation spread the panic, precipitating a stampede. Serious casualties occurred and many people had to be hospitalized for various reasons.

Eight patients with ARF were referred to King Fahd Hospital, Jeddah from smaller medical units around the site within 24 to 48 hours following the incident. There were six males and two females with an average age of 37.9 years. They comprised of three Saudis, three Turks and two Bangladeshis. All patients reported that in the tunnel they were pushed to the ground and were trotted upon. The clinical features of these patients at admission are given in [Table 1]. Two of them gave history of previous illnesses, namely flu-like illness with mild fever for the last few days in one, and history of noninsulin dependent diabetes mellitus in the other. None of the patients had any evidence of significant bodily injuries. The blood pressure was normal in all the patients. Six of the patients were oliguric and two were non-oliguric at the time of admission.

All patients had complete blood count, blood chemistry and urinalysis including orthotoluidine test performed on admission.

The results of the laboratory investigations at the time of admission are given in [Table 2]a and b. Most of the patients showed evidences of hemoconcentration. Renal function impairment was found to be moderate to severe. Serum transaminases were about ten times higher than normal limits and creatinine phosphokinase (CPK) values were many folds higher than normal. All patients had high-colored urine and all urine samples tested positive for occult blood (orthotoluidine dipstick test). None of the patients had significant erythrocyturia. Following admission, all the patients received -treatment according to the protocol [Table 3]. Intravenous fluids, loop diuretics and sodium bicarbonate (NaHCO3) infusions were given to achieve and maintain diuresis. Four patients were additionally given a trial of i.v. mannitol in a dose of 1gm/kg and two of them benefited from this. These patients had relatively low central venous pressure (CVP) on admission but hourly intravenous infusion of fluids as per protocol produced good diuresis in six of them within 48 hours. The two other patients remained oliguric; CVP was found to be 7 cm H2O or more. In these two patients, fluid administration was adjusted according to the urine output and these patients received on an average 225 mmol of NaHCO3 infusion per day. Three patients developed compartmental syndrome of leg(s) and one of them required fasciotomy. Five of the patients recovered from their renal failure with conservative medical management alone. The remaining three underwent haemodialysis (HD). One patient needed only one session of HD and another needed three sessions. The third patient was referred to another hospital upon request from his family after having received two HD sessions. His renal function was improving at the time of transfer [Table 4].


   Discussion Top


Our patients had renal failure due to rhabdomyolysis caused by trauma of human stampede. The cause of rhabdomyolysis seen in this group of patients is unique, and to the best of our knowledge, has not been reported so far. The basic mechanism seems to be direct pressure effect. It is possible that the relative lack of oxygen in the tunnel could have contributed to the muscle injury. In this study, the diagnosis of rhabdomyolysis was made based on clinical data, blood analysis showing high serum creatinine phosphokinase (CPK), high serum potassium (K+), low serum calcium (Ca++) and high phosphate and urine showing a positive orthotoluidine test in the absence of significant microscopic hematuria. These biochemical abnormalities appear in almost all the patients with rhabdomyolysis earlier than any rise in the serum creatinine levels and thus may be useful in predicting an ensuing renal failure [13] .

Early management of such patients to prevent acute renal failure is always advocated [5] . Large amounts of intravenous volume expanders are required in patients with shock and severe crush injuries. It is important to clear the tubules with a continuous flow of urine. Apparently, our patients did not receive adequate fluid replacement in the peripheral centers. In our center, they received varying amounts of intravenous fluids. A small dose of loop diuretic was used although it is said to have a theoretical disadvantage of acidifying the urine [14] . Regular NaHCO3 infusions can compensate and make the urine alkaline. It is known that alkalinity of the urine protects tubules from further pigment precipitation [15] .

The pathophysiology of altered calcium metabolism in oliguric patients is reported to be secondary to decreased levels of 1,25 (OH)2 D3 and skeletal resistance to parathyroid hormone [16] . The observation in our patients was that two of them were nonoliguric and their Ca+ +levels were more near normal as compared to the rest of the patients who were oliguric and had decreased Ca++ levels. In patients who went into diuresis, the Ca+ + levels became near normal. None of the patients developed hypercalcemia. The occurrence of hypercalcemia does not seem to be a consistent finding in such patients [17] .

Four of our patients who did not respond in the first 24 hours received mannitol infusion. Mannitol is a known renal vasodilator [18] and osmotic diuretic and may result in adequate increase in intratubular pressure to overcome tubular obstruction [19] caused by precipitated myoglobin. Probably, it is never too late to try mannitol particularly when the patient is well hydrated and the metabolic status has improved. However, in the patients who do not go into diuresis promptly, it may be wise to place a subclavian catheter as temporary vascular access and be ready for instituting dialysis therapy at any time. Three patients did need renal replacement therapy with haemodialysis. The indications were hyperkalemia in one patient and hyperkalemia and volume overload in the other two. All patients went into diuresis, however, one patient was transferred to another hospital on request after two sessions of HD.

Three of our patients developed compartmental syndromes but only one required fasciotomy while in the other two patients the swelling subsided gradually. The decision for fasciotomy should be reserved for the patients documented to have severe compression by direct manometry [20] . However if manometry is not available, clinical evidence of continuing rhabdomyolysis may indicate the need for rescue operation. Electromyographic examinations might also be helpful in making a decision to operate and, therefore, should be performed routinely [21] .

In conclusion, we present eight patients with rhabdomyolysis resulting from a rather unusual cause of trauma. Treatment with forced alkaline diuresis was beneficial in the majority of them. It is important to bear in mind rhabdomyolysis as the underlying cause in patients presenting with ARF after such incidents even if there are no apparent external injuries.

 
   References Top

1.Cadnapaphrnchai P, Taher S, McDonald FD. Acute drug associated rhabdomyolysis. Am J Med Sci 1980;280:6.  Back to cited text no. 1    
2.Eiser AR, Neff MS, Slifkin RF. Acute myoglobinuric renal failure A consequence of the neuroleptic malignant syndrome. Arch Intern Med 1982;142:601-3.  Back to cited text no. 2  [PUBMED]  
3.Akmal M, Valdin JR, McCarron MM, Masry SG. Rhabdomyolysis with and without acute renal failure in patients with phencyclidine Intoxication. Am J Nephrology 1981;l:91-6.  Back to cited text no. 3    
4.Chaiken HL. Rhabdomyolysis secondary to drug overdose and prolonged coma. South Med J 1980;73:990-4.  Back to cited text no. 4    
5.Ron D, Taitelman U, Michaelson M, Bar- Joseph G, Bursztein S, Better OS. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984;144:277-80.  Back to cited text no. 5    
6.McCarron DA, Elliott WC, Rose JS, Benett WM. Severe mixed metabolic acidosis secondary to rhabdomyolysis. Am J Med 1979;67:905-8.  Back to cited text no. 6    
7.Cunningham E, Kohli R, Venuto RC. Influenzaassociated myoglobinuric renal failure. JAMA 1979;242:2428-9.  Back to cited text no. 7  [PUBMED]  
8.Kreitzer SM, Ehrenpresis M, Miguel E, et al. Acute myoglobinuric renal failure in polymyositis. NY State J Med 1978;78:295.  Back to cited text no. 8    
9.Chugh KS, Singhal PC, Khatri GK. Rhabdomyolysis and renal failure following status asthmaticus. Chest 1978;73:879-80.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Berlin BS, Simon NM, Bovner RN. Myoglobinuria precipitated by viral infection. JAMA 1974;227:1414-5.  Back to cited text no. 10  [PUBMED]  
11.Vertel RM, Knochel JP. Acute renal failure due to heat injury. An analysis of ten cases associated with a high incidence of myoglobinuria. Am J Med 1967;43:435-51.   Back to cited text no. 11    
12.Leonard CD, Eichner ER. Acute renalfailure and transient hypercalcemia in idiopathic rhabdomyolysis. JAMA 1970;211:1539-40.   Back to cited text no. 12  [PUBMED]  
13.Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988;148:1553-7.  Back to cited text no. 13  [PUBMED]  
14.Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990;322:825-9.  Back to cited text no. 14  [PUBMED]  
15.Eneas JF, Schoenfeld PY, Humphreys MH. The effect of infusion of mannitol-sodium bicarbonate on clinical course of myoglobinuria. Arch Intern Med 1979;139:801-5.  Back to cited text no. 15  [PUBMED]  
16.Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25- hydroxycholecalciferol, and 1,25- dihydroxycholecalciferol. N Engl J Med 1981 ;3O5:l 17-23.  Back to cited text no. 16    
17.Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982;61:141-52.  Back to cited text no. 17  [PUBMED]  
18.Stahl W. Effect of mannitol on the kidney. N Engl J Med 1965;272:381.  Back to cited text no. 18    
19.Tanner GA, Steinhausen M. Tubular obstruction in ischemia-induced acute renal failure in the rat. Kidney Int (Suppl) 1976;6:S65-73.  Back to cited text no. 19  [PUBMED]  
20.Charles A Owen, Scot J. Mubarak, Alan R,et al. Intramuscular pressures with limb compression. N Engl J Med 1979;300:1169-1172.  Back to cited text no. 20    
21.Bogaerts Y, Lameire N, Ringoirs S. The compartmental syndrome: a serious complication ofacute rhabdomyolysis. Clin Nephrol 1982;17: 206-11.  Back to cited text no. 21    

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Correspondence Address:
Faissal A.M Shaheen
Consultant Nephrologist and Director, Jeddah Kidney Center, King Fahd Hospital, Jeddah
Saudi Arabia
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PMID: 18583757

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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