Acute Poisoning with Rhabdomyolysis in the Intensive Care Unit: Risk Factors for Acute Kidney Injury and Renal Replacement Therapy Requirement Pierre-François Rogliano 1,2 , Sebastian Voicu 1,2 , Laurence Labat 2,3 , Nicolas Deye 1 , Isabelle Malissin 1,2 , Jean-Louis Laplanche 2,4 , Dominique Vodovar 1,2 and Bruno Mégarbane 1,2, * 1
2 3 4
Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, 75010 Paris, France; [email protected]
(P.-F.R.); [email protected]
(S.V.); [email protected]
(N.D.); [email protected]
(I.M.); [email protected]
(D.V.) Inserm UMRS 1144, University of Paris, 75010 Paris, France; [email protected]
(L.L.); [email protected]
(J.-L.L.) Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, 75010 Paris, France Laboratory of Biochemistry, Federation of Toxicology APHP, Lariboisière Hospital, University of Paris, 75010 Paris, France Correspondence: [email protected]
; Tel.: +33-(0)1-4995-8961; Fax: +33-(0)1-4995-6578
Received: 22 August 2020; Accepted: 25 September 2020; Published: 28 September 2020
Abstract: Acute kidney injury (AKI) is the major complication of rhabdomyolysis. We aimed to identify the predictive factors for AKI and renal replacement therapy (RRT) requirement in poisoning-associated rhabdomyolysis. We conducted a cohort study including 273 successive poisoned patients (median age, 41 years) who developed rhabdomyolysis defined as creatine kinase (CK) >1000 IU/L. Factors associated with AKI and RRT requirement were identified using multivariate analyses. Poisonings mainly involved psychotropic drugs. AKI occurred in 88 patients (37%) including 43 patients (49%) who required RRT. Peak serum creatinine and CK were weakly correlated (R2 = 0.17, p < 0.001). Death (13%) was more frequent after AKI onset (32% vs. 2%, p < 0.001). On admission, lithium overdose (OR, 44.4 (5.3–371.5)), serum calcium ≤2.1 mmol/L (OR, 14.3 (2.04–112.4)), female gender (OR, 5.5 (1.8–16.9)), serum phosphate ≥1.5 mmol/L (OR, 2.0 (1.0–4.2)), lactate ≥ 3.3 mmol/L (OR, 1.2 (1.1–1.4)), serum creatinine ≥ 125 µmol/L (OR, 1.05 (1.03–1.06)) and age (OR, 1.04 (1.01–1.07)) independently predicted AKI onset. Calcium-channel blocker overdose (OR, 14.2 (3.8–53.6)), serum phosphate ≥ 2.3 mmol/L (OR, 1.6 (1.1–2.6)), Glasgow score ≤ 5 (OR, 1.12; (1.02–1.25)), prothrombin index ≤ 71% (OR, 1.03; (1.01–1.05)) and serum creatinine ≥ 125 µmol/L (OR, 1.01; (1.00–1.01)) independently predicted RRT requirement. We identified the predictive factors for AKI and RRT requirement on admission to improve management in poisoned patients presenting rhabdomyolysis. Keywords: acute kidney injury; poisoning; predictive factor; renal replacement therapy; rhabdomyolysis
1. Introduction Rhabdomyolysis is commonly reported in the poisoned patient with variable consequences ranging from a simple increase in serum creatine kinase (CK) to life-threatening electrolyte disturbances and acute kidney injury (AKI) requiring renal replacement therapy (RRT) [1,2]. In patients presenting rhabdomyolysis, a 13-50% risk of AKI [1–4] and up to 83% risk of mortality  have been reported.
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Mechanisms by which toxicants cause rhabdomyolysis are variable including prolonged unconsciousness and immobility, agitation, seizures, fall, withdrawal and hyperthermia [1,2]. Rarely, toxicant-induced direct effects (e.g., with cholesterol-lowering drugs of the statin class or with hair dye containing paraphenylenediamine) or nonspecific alterations in muscle ion homeostasis (e.g., binge drinking ethanol) are hypothesized. Rhabdomyolysis as a result of exposure to natural toxins is also often encountered after eating certain fish or mushroom species or being bitten by a snake or insect. Nutritional deficiencies, hypophosphatemia and hypokalemia may represent coexistent risk factors for the development of rhabdomyolysis . Risk factors for AKI in the presence of rhabdomyolysis include hyperkalemia, hyperphosphatemia, hypocalcemia, dehydration, acidosis, sepsis, intravascular volume depletion, high serum myoglobin concentrations and low myoglobin clearance [1,2]. In the poisoned patient, markers predictive of rhabdomyolysis-related renal complications have been poorly investigated despite the importance of being able to identify patients at risk to whom administering appropriate fluid rehydration with the goal of urine output of 300 mL/h is recommended . Serum CK level is routinely used as marker of severity although its correlation with the onset of consequent renal complications is rather weak [1,2]. We, therefore, designed a study aiming to analyze (1) the drugs involved; (2) the complications observed; and (3) the predictive factors for AKI, RRT requirement and death in those poisoned patients admitted to the intensive care (ICU) who developed rhabdomyolysis. 2. Materials and Methods 2.1. Study Design and Setting We conducted a single-center retrospective observational study. Our Hospital ICU is dedicated to poisoned patients, accounting for ~30% of the total admissions. The study was conducted according to the Helsinki principles and approved by our institutional review board (Commission Nationale de l’Informatique et des Libertés, N 2067659; date of approval, 26 May 2017). All poisoned patients admitted to the ICU between January 2012 and June 2018 and who developed rhabdomyolysis were included. Patients with preexisting myositis, myopathy, muscular dystrophy and CK elevation attributed to acute cardiac involvement or chronic renal failure were not included. Diagnosis of poisoning was made based on history, clinical findings and laboratory confirmations, when available. Patients were managed according to the national guidelines established by the French Intensive Care Society . Fluid management during the first 24 h to compensate dehydration or fluid losses before admission was monitored using ultrasound measurement of inferior vena cava diameter when required by the clinician in charge. 2.2. Parameter Definitions Rhabdomyolysis was considered if at least one serum CK concentration ≥ 1000 IU/L (i.e., ~5 times the upper-limit of normal) was identified during the ICU stay, as generally recognized [2,7,8]. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria . AKI was classified as “stage 1” if a 1.5 to 1.9-fold increase in serum creatinine during ICU stay was observed in comparison to the patient’s baseline concentration; as “stage 2” if a 2 to 2.9-fold increase was observed; and “stage 3” if at least 3-fold increase was observed and/or implementation of any RRT technique required. The patient’s baseline serum creatinine concentration was estimated using the Modification of Diet in Renal Disease (MDRD) formula, as recommended by the Acute Dialysis Quality Initiative (ADQI) working group, assuming a glomerular filtration rate (GFR) equivalent to 75 mL/min as described in previous studies [10,11]. Total loss of renal function and the final AKI stage were defined according to the duration of the episode (>4 weeks) and/or the need for RRT during >3 months.
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2.3. Data Collection We collected the usual demographic, clinical, biological, management and outcome data from the patients’ records. Prolonged immobilization was considered if signs of compression (redness, blisters, pressure ulcers) were reported by the physician when examining the patient’s skin. Serum and urinary myoglobin concentrations were not collected as not routinely measured in our ICU. When several data were reported, the most critical values close to the ICU admission were considered. 2.4. Statistical Analysis Data are expressed as the median (percentiles 25–75) or percentages as required. Variables were compared using Chi-2 or Fisher exact tests for the qualitative variables and Student t-tests for the quantitative variables. Variables significantly different at p < 0.2 were entered in multivariate logistic regression analyses with step-by-step selection procedure used to identify the variables independently associated with the risk of AKI, RRT requirement and death. For each quantitative variable, the analysis of the receiver operating characteristics (ROC) curve allowed the determination of the thresholds associated with the best sensitivity and specificity to predict the studied event (AKI, RRT or death). We calculated the odds ratio (OR) and their corresponding 95%-confidence intervals (CI). The performance of the predictive model was evaluated using the area under the curve (AUC) of the ROC curve (=1 for the optimal model and =0.5 for any model without a discriminating value). The statistical analyses were performed with XLAST® software (Microsoft Excel, Microsoft Corporation, Redmond, WA, USA, 2016). The statistical significance was set at p-value < 0.05. 3. Results 3.1. Study Population Two hundred and thirty-seven patients (138 men (58%)/99 women (42%); age, 41 years (31–53); new simplified acute physiology score (SAPSII) on admission, 33 (25–52)) were included. During the 7-year study period, 2418 poisoned patients were admitted to the ICU resulting in a prevalence of 9.8% for rhabdomyolysis in poisonings admitted to the ICU. The population characteristics are described in Table 1. Comorbidities were observed in 171 patients (72%). Attempted suicide by self-poisoning was reported in 222 patients (94%). Table 1. Characteristics of the study population. Parameters Demographics Age (years) Body mass index (kg/m2 ) Gender (Male/Female) Ethnicity Caucasian North-African Black African Asian Indian Exposure Intentional/Accidental Time from exposure to admission 24 h Medical history Past depression/suicide attempt Drug addiction Chronic alcoholism Psychosis Hypertension/coronary disease Human immunodeficiency virus infection Diabetes/dyslipidemia Long-term statin treatment Number of long-term medications
Median (Percentiles 25–75) or N (%) 41 (31–53) 23.6 (21.0–27.2) 138 (58%)/99 (42%) 181 (76%) 30 (13%) 18 (8%) 5 (2%) 3 (1%) 222 (94%)/15 (6%) 63 (29%) 64 (29%) 67 (31%) 26 (12%) 192 (81%) 87 (37%) 65 (27%) 56 (24%) 32 (14%) 19 (8%) 16 (7%) 9 (4%) 3 (1–5)
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Toxicants involved in the poisonings leading to to rhabdomyolysis were Toxicants involved in the poisonings leading rhabdomyolysis werepharmaceuticals pharmaceuticals(77%), (77%), drugs of abuse including ethanol (21%),(21%), household products (0.8%) and carbon (0.6%; Figure drugs of abuse including ethanol household products (0.8%) and monoxide carbon monoxide (0.6%; 1). The majority poisonings were multidrug ingestionsingestions (63%) mainly psychotropic drugs Figure 1). Theofmajority of poisonings were multidrug (63%)involving mainly involving psychotropic anddrugs ethanol (blood ethanol concentration on admission,on 1.13 g/L (0.29–2.01)). Traditional risk factors for and ethanol (blood ethanol concentration admission, 1.13 g/L (0.29–2.01)). Traditional rhabdomyolysis excluding possible excluding toxicant-related direct toxicity weredirect observed in 78were patients (33%)in risk factors for rhabdomyolysis possible toxicant-related toxicity observed including seizures prolonged (16%) and falls (4%). Four of neuroleptic 78 patients (33%)(18%), including seizuresimmobilization (18%), prolonged immobilization (16%) andcases falls (4%). Four cases malignant syndrome were reported. of neuroleptic malignant syndrome were reported.
Figure 1. Toxicants involved in the poisonings with rhabdomyolysis based on the medical history (with Figure 1. Toxicants in the poisonings with rhabdomyolysis based on the medical history (with their respectiveinvolved percentages noted above the bars). their respective percentages noted above the bars).
3.2. Features, Complications and General Management
3.2. Features, Complications and General Management in Table 2. Complications at any point of ICU stay Features on admission are summarized included pneumonia (54%), AKI (37%), failure (35%), arrest (14%), Featuresaspiration on admission are summarized in Table 2. cardiovascular Complications at any point ofcardiac ICU stay included disseminated intravascular coagulation (12%), hospital-acquired infections (8%) and compartment aspiration pneumonia (54%), AKI (37%), cardiovascular failure (35%), cardiac arrest (14%), syndrome (2%). Management included(12%), fluidshospital-acquired (100%), antibioticsinfections (61%), mechanical ventilation (52%), disseminated intravascular coagulation (8%) and compartment catecholamines (35%), 1.4% sodiumfluids bicarbonate RRT (61%), (18%) mechanical and extracorporeal membrane syndrome (2%). Management included (100%),(19%), antibiotics ventilation (52%), oxygenation (35%), (11%). 1.4% sodium bicarbonate (19%), RRT (18%) and extracorporeal membrane catecholamines oxygenation (11%).
Table 2. Clinical features of the poisoned patients with rhabdomyolysis on admission to the intensive care unit.
Table 2. Clinical features of the poisoned patients with rhabdomyolysis on admission to the intensive Parameters Median (Percentiles 25–75) or N (%) care unit. Glasgow coma score 8 (3–14) Parameters Median (Percentiles 25–75) or N (%) Systolic blood pressure (mmHg) 116 (101–135) Glasgow blood coma score (3–14) Diastolic pressure (mmHg) 728(58–83) 116 (101–135) Systolic blood Heart pressure (mmHg) rate (/min) 93 (75–105) DiastolicRespiratory blood pressure 72 (14–21) (58–83) rate(mmHg) (cycles/min) 17 Heart rate (/min)(12–20/min) 93 (75–105) Normopnea 134 (58%) 17 Respiratory rate (cycles/min) Tachypnea (>20/min) 80 (14–21) (35%) 134 (58%) Normopnea (12–20/min) Bradypnea (20/min) Agitation/confusion 73 Bradypnea (