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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 643-646
Rhabdomyolysis and acute kidney injury after acupuncture sessions


1 Department of Internal Medicine-Nephrology, University Hospital of Patras, Patras, Greece
2 Department of Internal Medicine-Endocrinology, Attikon University Hospital, Athens, Greece
3 Internal Medicine Department, General Hospital of Sparti, Sparti, Greece

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Date of Web Publication9-May-2014
 

   Abstract 

Rhabdomyolysis is usually caused by muscle injury, drugs or alcohol and presents with muscle weakness and pain. It is characterized by rise in serum creatine kinase, aminotransferases and electrolytes as well as myoglobinuria. Myoglobinuria may cause acute kidney injury by direct proximal tubule cytotoxicity, renal vasoconstriction, intraluminal cast formation and distal tubule obstruction. Muscle pain and weakness as well as vascular injury have been reported after acupuncture. We report a case of severe rhabdomyolysis and acute kidney injury after acupuncture sessions.

How to cite this article:
Papasotiriou M, Betsi G, Tsironi M, Assimakopoulos G. Rhabdomyolysis and acute kidney injury after acupuncture sessions. Saudi J Kidney Dis Transpl 2014;25:643-6

How to cite this URL:
Papasotiriou M, Betsi G, Tsironi M, Assimakopoulos G. Rhabdomyolysis and acute kidney injury after acupuncture sessions. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2017 Dec 13];25:643-6. Available from: http://www.sjkdt.org/text.asp?2014/25/3/643/132223

   Introduction Top


Rhabdomyolysis is the lysis of the skeletal muscle, during which electrolytes (potassium, phosphorus), myoglobin, creatine kinase (CK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and other proteins are released from the muscle cells into the circulation. [1],[2] The most common causes are muscle trauma, either direct or from over-exertion, alcohol abuse and consumption of certain drugs. [1],[2] The most common symptoms are muscle weakness, myalgia and high colored urine. Acute kidney injury (AKI) due to myoglobinuria is a potentially lethal complication of rhabdomyolysis. Many cases of rhabdomyolysis complicated by AKI have been published, but none has been reported due to acupuncture as the cause. We report a case of severe rhabdomyolysis and acute renal failure following acupuncture sessions.


   Case Report Top


A 64-year-old man was referred to the Emergency Department of the General Hospital of Sparti because of pain and weakness of the lower extremities as well as balancing disorders for the last 24 h. There was no history of dysphagia, dysarthria or diplopia. The day before admission, he had fainted but had no evidence of trauma. He had no history of fever, cough, sore throat or diarrhea during the preceding month.

The patient mentioned that during the last six days he had undergone acupuncture sessions localized to the legs because of osteoarthritis of the knees and subsequent arthralgias for months.

His medical history included diabetes mellitus, hypertension and hypothyroidism, and he was on treatment with metformin 850 mg once daily, lisinopril 20 mg daily and hydrochlorothiazide 25 mg twice daily and L-thyroxin 0.1 mg once daily. He was also receiving 80 mg of aspirin daily.

Physical examination at presentation was normal, apart from mild tachycardia and reduced muscle strength of his lower extremities. Blood pressure was 143/96 mm Hg, pulse rate was 110 beats/min and body temperature was 37.1°C. Examination of the lungs, heart and abdomen was normal. The patient's lower limbs showed no edema and no color change (pallor, cyanosis), and the pulses of his peripheral arteries were palpable. Neurological examination and tendon reflexes were normal.

Laboratory tests showed CK 81,400 U/L, serum creatinine (Cr) 1.5 mg/dL, blood urea nitrogen 68 mg/dL, SGOT 1063 U/L, alanine aminotrasferase (AST) 244 U/L and LDH 2617 U/L. Complete blood count was normal. On admission, his serum glucose was 168 mg/ dL, while serum sodium (Na) was 138 mmol/ L, potassium (K) was 3.5 mmol/L, calcium (Ca) was 8.6 mg/dL and phosphorus (P) was 4.4 mg/dL. Urinalysis showed cola-colored urine (hemoglobinuria) and mild proteinuria, but only occassional erythrocytes and leukocytes. There were no casts. Arterial blood gas analyses showed a pH of 7.49, pCO 2 of 35 mm Hg, pO 2 of 102 mm Hg and bicarbonate (HCO 3 - ) of 24 mmol/L. Chest radiography showed a mildly high cardiothoracic index. The electrocardiogram showed sinus tachycardia (110 pulses/ min).

The patient was admitted to the internal medicine department for further investigation of rhabdomyolysis as well as for the monitoring and treatment of his renal dysfunction. Troponine and CK-MB were normal. Uric acid was 11.5 mg/dL. HBsAg, anti-HCV and HIV testing were negative. Prothrombin time, activated partial thromboplastin time and INR were also normal during his hospitalization. TSH was 0.2 mU/L, total T 4 was 9.4 μg/dL and total T 3 was 0.68 nmol/L the day after his admission to the hospital, suggesting probably low T 3 syndrome (euthyroid sick syndrome). ANA and Ra test were negative. Blood and urine cultures, antistreptolysin O, as well as serological tests for Epstein-Barr virus, Cyto-megalovirus, Herpes Simple virus, Coxsackie and Echo viruses were also negative.

The patient was treated with intravenous normal saline infusion. On the second day of his hospitalization, the patient developed non-oliguric AKI (Cr 2.6 mg/dL); moreover, his serum phosphorus rose to 5.9 mg/dL, while the serum total calcium was 7.5 mg/dL. The serum Cr value peaked on the 4 th day from his admission, while after the 5 th day his renal function progressively improved and his serum CK steadily decreased [Figure 1]. On the 12 th day after admission, his renal function returned to normal (Cr 1.3 mg/dL) without a need for hemodialysis and serum CK, P and Ca also normalized and muscle weakness improved significantly.
Figure 1: Creatinine and creatine kinase values progression during hospitalization.

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   Discussion Top


We present a case of rhabdomyolysis and subsequent AKI induced by no obvious cause other than acupuncture. Diagnosis of rhabdomyolysis was based on clinical (muscle weakness) and laboratory findings (elevated serum CK, SGOT, LDH, P, uric acid and hemoglobinuria). It is well known that urine dipstick does not differentiate between hemoglobulin and myoglobulin.

Physical causes and trauma can lead to rhabdomyolysis. [1],[2] Although we cannot define the precise mechanism that induced rhabdomyolysis, we assume that the inserted acupuncture needles could cause muscle trauma or vascular injury, [3] which might lead to muscle ischemia. Symptoms similar to our patient (extremity pain, fainting or dizziness) have been frequently reported after acupuncture. [4],[5],[6] There have also been a few reports of myositis, [5] hematuria, [4] knee weakness [4] and difficulty in walking [4] after acupuncture.

The patient had no recent history of strenuous exercise, seizures or prolonged immobilization that could induce rhabdomyolysis. He had received no statins or any other drugs (anti-psychotics, antidepressants, sedatives, anesthetics, etc.) or alcohol, which can cause rhabdomyolysis. [1],[2] Furthermore, he showed no evidence of infection (no recent history of suspicious symptoms, normal chest radiograph, negative cultures, etc.) that could lead to acute rhabdomyolysis. [1],[2] Hyperthyroidism, hypothyroidism and diabetic ketoacidosis [1],[2] have been associated with rhabdomyolysis, [1] but they can be ruled out in this case, as our patient was euthyroid and his arterial blood gases and serum glucose values on admission day were not consistent with ketoacidosis. Negative autoantibody testing and absence of proximal muscle weakness made diagnosis of polymyositis or dermatomyositis, which are rare causes of rhabdomyolysis, less possible. [1],[2] The patient mentioned that he had no history of recurrent rhabdomyolysis, suggesting that an inherited disorder of muscle metabolism could be ruled out. [1],[2] Finally, he had no electrolyte abnormalities that could cause (hyponatremia, hypernatremia, hypokalemia, hypophosphatemia) rhabdomyolysis. [1],[2]

Rhabdomyolysis and myoglobulinuria can cause renal injury by direct proximal tubule cytotoxicity, renal vasoconstriction, distal tubule obstruction and intraluminal cast formation. [1],[2] Myoglobulin is not effectively removed by dialysis. [2] Continuous venovenous hemofiltration may remove myoglobin in patients with rhabdomyolysis and acute kidney injury and oliguria. [7] However, myoglobin will probably fall either with fluid administration alone or after hemofiltration and/or dialysis, independently of renal function. [8]


   Conclusion Top


We present a rare case of rhabdomyolysis inducing AKI due to acupuncture. Further studies are needed to determine whether such a common practice is a cause of severe rhabdomyolysis and under what contributing conditions.


   Conflict of Interest Top


All authors did not receive any sponsorship or funding arrangements related to this article. The results presented in this paper have not been published previously in whole or part.

 
   References Top

1.Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis - An overview for clinicians. Crit Care 2005;9:158-69.  Back to cited text no. 1
    
2.Bosch X, Poch E, Grau JM. Rhabdomyolysis and Acute Kidney Injury. N Engl J Med 2009;361:62-72.  Back to cited text no. 2
    
3.Bergqvist D. Vascular Injuries caused by acupuncture. Eur J Vasc Endovasc Surg 2008; 36:160-3.  Back to cited text no. 3
    
4.MacPherson H, Thomas K, Walters M, Fitter M. A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupunct Med 2001;19:93-102.  Back to cited text no. 4
    
5.Norheim AJ, Fønnebø V. Adverse effects of acupuncture. Lancet 1995;345:1576.  Back to cited text no. 5
    
6.Ernst E, White AR. Prospective studies of the safety of acupuncture: A systematic review. Am J Med 2001;110:481-5.  Back to cited text no. 6
    
7.Wakabayashi Y, Kikuno T, Ohwada T, Kikawada R. Rapid fall in blood myoglobin in massive rhabdomyolysis and acute renal failure. Intensive Care Med 1994;20:109-12.  Back to cited text no. 7
    
8.Zhang L, Kang Y, Fu P, et al. Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury: A case series. Injury 2010;43: 619-23.  Back to cited text no. 8
    

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Correspondence Address:
Dr. Marios Papasotiriou
Department of Internal Medicine-Nephrology, University Hospital of Patras, Patras 265 00
Greece
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DOI: 10.4103/1319-2442.132223

PMID: 24821167

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
   Conflict of Interest
    References
    Article Figures
 

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