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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1997  |  Volume : 8  |  Issue : 2  |  Page : 131-133
Rhabdomyolysis and Acute Renal Failure Secondary to Toxic Material Abuse in Morocco


Service de Nephrologie-Hemodialyse, CHU Ibn Rochd, Casablanca, Morocco

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   Abstract 

We have studied 26 patients with rhabdomyolysis complicated with acute renal failure. The causes of rhabdomyolysis were dominated by paraphenylene diamine intoxication (PPD) (13 cases). The other etiologies were: crush syndrome (6 cases), eclampsia (3 cases), intense physical effort (1 case), butane intoxication (1 case), postural rhabdomyolysis induced by a prolonged surgical operation for pheochromocytoma (1 case). None of the patients had any past medical history of muscle or renal disease. Serum level of creatinine phosphokinase varied from 1200 to 5400 IU/L. The mean peak of serum creatinine level was 620 umol/1. Therapy included forced alkaline diuresis in all cases. Hemodialysis was required in 18 cases. All but eight patients survived. We conclude that rahabdomyolysis could be caused by intoxication, which was a prime cause in this study. Prevention may be possible with restriction of use of toxic products.

Keywords: Rhabdomyolysis, Acute renal failure, Paraphenylene diamine, Hemodialysis.

How to cite this article:
Fatihi E, Ramdani B, Benghanem MG, Hachim K, Zaid D. Rhabdomyolysis and Acute Renal Failure Secondary to Toxic Material Abuse in Morocco. Saudi J Kidney Dis Transpl 1997;8:131-3

How to cite this URL:
Fatihi E, Ramdani B, Benghanem MG, Hachim K, Zaid D. Rhabdomyolysis and Acute Renal Failure Secondary to Toxic Material Abuse in Morocco. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2019 Dec 14];8:131-3. Available from: http://www.sjkdt.org/text.asp?1997/8/2/131/39385

   Introduction Top


The first cases of rahabdomyolysis were described by Bywaters [1] in 1941. This disease is characterized by lysis of muscle cells, which leads to several metabolic disturbances including precipitation of myoglobin in renal tubules and acute renal failure (ARF). There are various causes of rahabdomyolysis, but trauma is a dominant factor [1] . The purpose of this study is to highlight the frequency PPD intoxication as a dominant cause of rhabdomyolysis in Morocco.


   Patients and Methods Top


Twenty six cases of rahabdomyolysis with severe ARF in one center were studied during a ten-year period from December 1984 to December 1994. The ages of the patients ranged from 15 to 60 years with a mean of 37 years. The criteria for diagnosis of rhabdomyolysis inducing ARF were:

1) Increase of phosphokinase creatinine (PKC) over 1000 IU/L in the absence of cardiac ischemia.

2) Elevated blood urea niterogen more than 18 mmol/1.

3) Elevated serum creatinine more than 200 umol/1.

4) Hyperkalemia.

5) Metabolic acidosis.

6) Absence of signs of intravascular hemodialysis (hemoglobinuria, hyper­bilirubinemia, methemoglobinemia).

For each patient, the medical history and physical examination were available for evaluation.


   Results Top


None of the patients had any past medical history of muscle or renal disease. The clinical presentation of all patients was severe because of metabolic disturbances. All the patients had oligoanuria with dark urines and myalgia. Severe hyperkalemia with cardiac symptoms was observed in 18 cases (69%). Hypocalcemia (< 1.5 mmol/L) was observed in 3 cases (11.5%). Severe metabolic acidosis was observed in 20 cases (77%).

The causes of rhabdomyolysis were variable in this study. They were dominated by toxic etiologies, particularly paraphenylene diamine (PPD), as shown in [Table - 1]. Thirteen patients (50%) ingested this substance in suicidal attempts. In addition to the signs of rhabdomyolysis, the clinical presentation of PPD intoxication included oedema of neck and face, macroglossia and respiratory disturbances leading to distress. Blood levels of PPD were not determined, so correlation with the severity of clinical signs were not established. The second cause in this study was post-traumatic rhabdomyolysis (6 cases). The trauma was multiple, involving arms and thorax (crush syndrome).

Severe eclampsia leading to rhabdomyolysis was observed in three cases. After repeated and prolonged seizures, the pregnant women developed oligoanuria and elevation of CPK. There was one case of postural rhabdomyolysis induced by a prolonged surgical excision of pheochromocytoma. There was one case of rhabdomyolysis, which was probably due to viral infection. There was one case of Butane intoxication, and another case of Marathon racing related rhabdomyolysis.

Serum level of creatinine phosphokinase varied from 1200 to 5400 IU/L. The mean peak of serum creatinine level was 620 umol/1. Therapy included forced alkaline diuresis in all cases. Hemodialysis was required in 18 cases.

Eight (30.8%) patients died; Five because of extrarenal manifestations of crush syndrome, and three patients were due to nosocomial infection. Normal renal function was regained in the 18 surviving patients after a duration of 18 + 3 days, which concided with their biological and clinical recovery of rhabdomyolysis.


   Discussion Top


The incidence of rhabdomyolysis as a cause of ARF is estimated to be between 5-10% in the literature [2],[3] . In our experience, rhabdomyolysis contributes to 10% of etiologies of ARF [4] . Several authors have reported severe ARF induced by rhabdo­myolysis [2],[5],[6] . As expected, the clinical presentation of the patients in our study was so severe it necessitated early hemodialysis.

Severe hypocalcemia, which may be explained by cell lysis resulting in hyper­phosphatemia and formation of phosphate­calcium complexes, was observed in our study and by others [7] . Rhabdomyolysis can result from several causes. In our study, the toxic causes were frequent, while they are rare in literature [3] . This high incidence can be explained by the availability and common use of PPD in suicidal attempts.

In renal failure secondary to rhabdomyo­lysis, tubular necrosis is usually associated with the precipitation of myoglobin in the renal tubules [8],[9] . However, we did not perform any renal biopsy in our study patients.

The majority of our patients (69%) required hemodialysis. This therapy is largely indicated in rhabdomyolysis complicated with ARF [10],[11] . Other lines of therapy include forced diuresis by infusion of abundant liquids and alkali [12] .

We conclude that rhabdomyolysis can be caused by toxic materials including PPD. This study demonstrates the high frequency of intoxication by PPD in our country. ARF induced by rhabdomyolysis is usually severe and requires intensive therapy including dialysis.

 
   References Top

1.Bywaters EG, Beall D. Crush injuries with impaircment of renal function. Br Mcd J 1941;l:427-32.  Back to cited text no. 1    
2.Grossman RA, Hamilton RW, Morse BM, Penn AS, Goldberg M. Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med 1974;291:307-11.  Back to cited text no. 2    
3.Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure in rhabdomyolysis. Austr N Z J Mcd 19S8;148:623-8.  Back to cited text no. 3    
4.Moujib S. Insuffisance renal aigue medical thesis Casa 1992;5:623-8.  Back to cited text no. 4    
5.Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988;148:1553-7.  Back to cited text no. 5  [PUBMED]  
6.Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine Baltimore 1982;61:141-52.  Back to cited text no. 6  [PUBMED]  
7.Gabow B, Lazard T, Vassal T, Guglielminotti J, Offenstadt G. Mcanismes de 1'insuffisance renale aigue au cours dc la rhabdomyolyse. Rean Med Urgence 199 4; 7:249-62.  Back to cited text no. 7    
8.Cooper PN, Tapson J, Morley AR. Immunoperoxidase technique and histology in the diagnosis of rhabdomyolysis related acute renal failure. J Clin Pathol 1992;45:825-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Adnet P, Tavernier B, Handecoeur G, KrivosieHobber R. Rhabdomyolysis: hypotheses physiopathologiques. Rean Med Urgence 1994;7:238-47.  Back to cited text no. 9    
10.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. 10  [PUBMED]  
11.Collins AJ, Burzstein S. Renal failure in disasters. Crit Care Clin 1991;7:421-35.  Back to cited text no. 11  [PUBMED]  
12.Better OS. The crush syndrome revisited (1940-1990) Nephron 1990;55:97-103.  Back to cited text no. 12    

Top
Correspondence Address:
Driss Zaid
Service de Nephrologie-Hemodialysis, CHU Ibn Rochd, Casablanca
Morocco
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PMID: 18417791

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    References
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