| NKF: National Kidney Foundation Spring Clinical Meetings Report |
Rhabdomyolysis Can be Caused by Hazing, Medication Interaction and Anesthetics
Las Vegas, NV 2011--A muscle condition that injures the kidneys is well-known to football experts -- diagnosed recently in a professional player and 13 college athletes. Yet new studies are finding some surprising sources of rhabdomyolysis, the potentially deadly condition, according to research being presented at the National Kidney Foundation's Spring Clinical Meetings, held here this week.
This condition causes muscles to break down, releasing their fibers and enzymes into the body. These enter the bloodstream and plug up the kidney, resulting in potentially fatal damage. Recently, the condition was diagnosed in Washington Redskins player Albert Haynesworth and 13 players on an Iowa college team, as well as two dozen high school football players in Oregon. In these cases, the condition – often called simply "rhabdo" – is attributed to intense workouts, injury, or heat exhaustion. But there are less obvious causes that can put even non-athletes at risk.
One group of researchers presented findings from a 19-year-old man who developed rhabdo after being hazed by his fraternity. As part of the hazing, he was struck in the back and buttock areas up to 1,000 times with wooden paddles, injuring the muscles and triggering rhabdomyolysis.
"This is yet another reason why hazing can be deadly," said study author Dr. Khalid Bashir of the Morehouse School of Medicine. Thankfully, with treatment, the man survived. "The strange thing is that the patient entered a fraternity thinking his brothers would protect him from other people," said Dr. Bashir. "When, in fact, it was the other way around."
In another study, Dr. Gaurav Alreja at Baystate Medical Center and his colleagues describe a man who developed rhabdo after taking the combination of a cholesterol-lowering drug and an antibiotic.
Previous research has shown that these cholesterol-lowering drugs, known as statins, can increase the risk of rhabdo, explained Dr. Alreja. In this instance, a 73-year-old man on a relatively high dose of simvastatin developed rhabdo after he added the antibiotic azithromycin – a common drug thought to be very safe, he explained.
"This patient likely had some predisposition to developing rhabdomyolysis, and the high dose of the statin increased that risk – adding this antibiotic likely tipped the balance," said Dr. Alreja. "Hopefully, doctors and patients will keep this interaction in mind when offering antibiotics to patients receiving statins."
Thankfully, the patient recovered, and was able to continue taking high-doses of statins without the antibiotic, and the rhabdo did not return.
In another less fortunate report, doctors describe a 24-year-old man who died after developing rhabdomyolysis as a complication from anesthesia. The man had been under anesthesia for days following a car accident, and patients in this situation are sometimes at risk of developing propofol infusion syndrome (PRIS), a series of complications resulting from the anesthetic propofol.
In this instance, the patient developed rhabdomyolysis as well, and died.
Many people – even doctors – may not be aware that PRIS can cause rhabdomyolysis, and hopefully this man's tragedy will help change that, said study author Dr. Tamim H. Naber of the Hofstra North Shore-LIJ School of Medicine. "Knowledge of this rare condition is important to help diagnose the condition early, and potentially stop the course of the disease," said Dr. Naber.
"These studies illustrate the importance of overall awareness of the many uncommon causes of rhabdomyolysis, which can have devastating effects on athletes and non-athletes alike," said Dr. Lynda Szczech, National Kidney Foundation President.
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HAZING INDUCED RHABDOMYOLYSIS AND ACUTE KIDNEY INJURY (AKI).
Khalid Bashir, Anju Oommen, Alsadek Sultan, Dept. of Medicine,
Morehouse School of Medicine, Atlanta, GA, USA; Suhail Akbar,
Saghir Ahmed, CGKS, GA, USA.
Hazing practices have become increasingly prevalent in schools
within fraternities, sororities and athletic teams, as well as in
nonacademic settings including the military and street gangs. Hazing is
used for an individual to be initiated into an organization. Some of
these acts can put the individual at risk for injury. Scant information
about renal involvement from hazing is available in the literature.
A 19 year old man with no past medical problems presented with
complaints of generalized aches, chills, back pain, right hand pain, and
urine discoloration after suffering “an accident”. On further
questioning, patient stated that he had joined a “membership until
fraternity” upon admission to a state college. For the last three months
he had been subjected to hazing by receiving 700 to 1000 hard blows to
his buttock areas and back with wooden paddles. This was done
between hours of 10 pm and 3 am in off-campus secluded wooden
areas.
Physical examination revealed a well built male, blood pressure of
133/92, temperature of 99.5º F, with extensive bruising on the lower
back, both buttocks and upper thighs. Laboratory abnormalities
revealed BUN 89 mg/dl, serum creatinine 13.7 mg/dl, calcium 7.8
mg/dl, phosphorus 9.7 mg/dl, magnesium 2.5 mg/dl, CPK 367.3 u/L,
aldolase 13.3 u/L, and moderate hematuria. Renal ultrasound showed
normal sized kidneys with increased echotexture. Percutaneous renal
biopsy revealed 10% focal acute tubular injury with occasional muddy
red-brown casts, with no chronicity and no immune complex disease.
Patient required intermittent hemodialysis for 8 days with subsequent
recovery of renal function.
Hazing can cause traumatic rhabdomyolysis and AKI. A common
misconception exists among college students (as in our case) that once
admitted, the fraternity would do its part to protect the individual from
acts including hazing. Thorough education at community grass root
level, in addition to utilization of legislation and institutional policies
may prevent hazing and its associated severe traumatic injuries.
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RHABDOMYOLYSIS CAUSED BY UNUSUAL INTERACTION
BETWEEN SIMVASTATIN AND AZITHROMYCIN
Gaurav Alreja, Sadiq Inayatullah, Saurabh Goel, Gregory Braden
Baystate Medical Center, Tufts University, Springfield, Massachusetts.
Rhabdomyolysis (rhabdo) is an uncommon but life-threatening
adverse effect of statin therapy. We report a rare case of rhabdo caused
by potential drug interaction between simvastatin and azithromycin.
A 73 yr Caucasian male with history of chronic kidney disease stage
3 due to idiopathic interstitial nephritis (baseline Cr 1.7 mg/dl),
diabetes mellitus, hypertension, hyperlipidemia presented with
weakness of lower extremities for 1 week. His medications included
allopurinol prednisone, labetalol, bumetanide and simvastatin 80 mg/d
(for 2 yrs). He received Azithromycin (AZI) 500 mg followed by 250
mg daily for next 4 days, 1 wk ago for acute bronchitis. He was found
to have rhabdo with CPK of 11,240 U/L and Cr of 3.8 mg/dl.
Discontinuation of simvastatin with IV hydration and bicarbonate
resulted in resolution of rhabdo. Simvastatin was reintroduced at 40
mg/d after 2 months and later increased to 80 mg/d without any
subsequent recurrence of myalgia or weakness.
Rhabdo related deaths have been reported with all statins except
fluvastatin. Important variables affecting its occurrence include statin
dose, patient characteristics and concurrent use of other medications
that may alter the pharmacokinetics of the statins. Simvastatin and
lovastatin are metabolized by CYP3A4, AZI by both CYP3A3 & 3A4
and fluvastatin by CYC2C9 enzyme system. Macrolides inhibit
CYP3A4, thus elevating the statin levels. However, AZI (an azalide,
subclass of macrolide) interferes poorly with CYP3A4 & after hepatic
metabolism gets excreted in the bile. Although, rhabdo with AZI &
lovastatin has been previously reported, this is a rare reported case of
rhabdo caused by co-administration of AZI and simvastatin.
Polymorphism of CYP3A4 might explain such rare cases despite
insignificant inhibition by AZT in studies. Interference in biliary
excretion of statins by AZT (through P-glycoprotein and multi drug
resistance protein) might be another mechanism. His advanced age,
underlying CKD and high dose of simvastatin might also have
contributed to this rare complication. In conclusion, AZI might be co-
administered with statins, with caution as there is risk of rhabdo.
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Home Dialysis Summit Recommends Policy Changes to Increase Home Dialysis Usage
WASHINGTON, April 25, 2012 /PRNewswire -- On the heels of the first National Summit on Home Dialysis Policy, Summit organizers released a report reflecting the views of the delegates -- leaders in the kidney disease patient, clinician, facility and industry communities -- on federal policy steps to improve utilization of home dialysis for patients who can benefit from this often advantageous form of treatment. Many of the organizers also announced they have formed a new alliance, called the Alliance for Home Dialysis, to advance the recommendations identified at the Summit.
The Summit's "Report of the Delegates" highlights key findings from a March 29th meeting in Washington, DC where experts probed why, despite widely accepted and well-documented benefits of home dialysis -- improved outcomes, enhanced patient satisfaction, improved quality of life, and lower costs-- fewer than ten percent of the more than 390,000 current U.S. dialysis patients receive treatment at home. Current rates of home dialysis utilization reflect a steep decline from the 1970s, when almost 40% of U.S. dialysis patients were treated in-home.
Specifically, delegates found that policymakers should work with stakeholders in the dialysis community to confront three areas:
Accessibility: Patients and clinicians face array of hurdles in education, training, and infrastructure that hinder equalized access to home dialysis.
Accountability: Utilization of home dialysis can be improved through measures within government programs that are designed to recognize and support excellence in the delivery of home dialysis services.
Aligning Incentives: Reimbursement policies, regulation of new technologies and other policy incentives can be realigned to better support federal policy goals of expanding access to home dialysis.
The Report includes 15 recommendations to serve these goals, including that federal policymakers should:
Maintain parity for home and in-center dialysis in Medicare reimbursement;
Support home dialysis mentoring programs, particularly those that use existing patients as mentors; and
Align federal and state regulatory requirements for home therapies, such as revising the Centers for Medicare and Medicaid Services Conditions for Coverage requirements, to reflect differences in home and in-center dialysis.
Summit supporters will begin work through the new Alliance to dialogue with federal policymakers and advance policy improvements in the three consensus areas that emerged at the Summit.
SOURCE National Summit on Home Dialysis Policy
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National Kidney Foundation's Top 10 Things Every Dialysis Patient Should Know.
- You have treatment choices. Options exist for how, where and when you dialyze. Dialysis can be done in a hospital, in a dialysis unit that is not part of a hospital, or at home. You and your doctor will decide which place is best, based on your medical condition and your wishes. There are different types of dialysis - peritoneal and hemodialysis. Work with your health care team to determine a treatment plan that makes you feel comfortable. Recent studies show that the majority of patients beginning in-center hemodialysis (HD) know very little, if anything, about the option to dialyze at home. Once informed, 40% or more of patients are interested in this treatment option, and yet less than 10% actually begin home dialysis. If you're dissatisfied with the type of dialysis treatment that you're receiving, ask your healthcare team if another type of dialysis treatment would be better.
- You can compare in-center dialysis facilities online. Information on over 5,600 US-based dialysis centers is available online through the Medicare website. To help you make choices about your care, you can compare different facilities side-by-side and evaluate each facility based upon clinic characteristics and quality measures. You can search for dialysis facilities by name or geographic proximity. After completing an initial facility comparison to determine which facilities best meet your needs - such as the number of hemodialysis stations at a particular location and whether there are evening shifts available - visit the facilities that you're most interested in. Talk to the staff and other patients, as well as your doctor to ensure that this dialysis facility is a good fit for you.
- There are ways to prepare ahead for an emergency. Ask your dialysis facility about their emergency plan in case of a snow storm, fire, power outage or other natural disaster. As back up, make sure you have the names, locations and phone numbers of other dialysis units and hospitals in your area. Since regular community transportation services may not be working in an emergency, be prepared to make other arrangements for getting to dialysis. You may need to contact the police and Emergency Medical Services (EMS) for assistance. If you dialyze at home, make sure you have at least two weeks' worth of unexpired supplies on hand. If you have to miss a dialysis treatment, begin your emergency meal plan.
- There is an easy way to transfer patient records between clinics. There is an easy, secure way for your health care team to transfer your treatment records online. In 2009, the Centers for Medicare and Medicaid Services (CMS) created a centralized web-based data collection system called CROWNWeb to help reduce and eliminate patient treatment interruptions. This central system helps to streamline patient care regardless of the reason for changing dialysis centers. For example, if you've been admitted to the hospital, or if you needed to relocate during an emergency evacuation, your doctors and health care team can access up-to-date information about your dialysis so that you continue to receive appropriate care no matter where you are.
- You can travel while on dialysis.
Dialysis centers are located in every part of the United States and in many foreign countries. The treatment is standardized, but you need to plan ahead by making an appointment for dialysis at another center before you go. The staff at your center may help you make these appointments.
- You can be your own best advocate. Know what key questions to ask your doctor or other healthcare professionals. Take notes so that you can refer back to them later. Partner with your doctor and decide on a treatment plan together. Advocate for yourself and share how you're feeling.
- You have many rights. You as a patient have a great deal of control over your treatments. Patients have a bill of rights which includes receiving quality care, counseling about your medical information, and an expectation of privacy.
You also have responsibilities. Once you decide on a course of treatment, it's important to follow the recommendations of your health care team. If you decide to receive in-center dialysis, arrive at dialysis on time so that you can receive the full treatment without delays.
- You can receive insurance coverage. If you have end stage renal failure, you are likely eligible for Medicare insurance coverage. Speak with your health care team and social worker for help filling out insurance paperwork.
- You may need to follow a special diet. When your kidneys are not working properly, you may not be able to eat everything you like, and you may need to limit how much you drink. Your diet may vary according to the type of dialysis you receive. It is important to speak with a renal dietitian so that you are able to understand what you can and cannot eat based on your full health history.
- Dialysis patients can work. Many dialysis patients can go back to work or school after they have gotten used to dialysis. After establishing a dialysis routine, many patients have more energy and find that they are able to time to work around this new schedule. Some patients even find creative ways to work remotely from dialysis with the use of a laptop or cell phone, depending on their field of expertise.
More from National Kidney Foundation Press Releases
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New Book to Help Educate Patients with Chronic Kidney Disease who may be facing Dialysis or Hemodialysis: |
Help, I Need Dialysis!
How to have a good future with kidney disease
By Dori Schatell, MS and Dr. John Agar
An internationally known nephrologist and life-long kidney patient educator explain how dialysis works, each of the ways to do it, and how your treatment choice may affect your diet, energy level, work, travel, sexuality and fertility, sleep, and survival. Comprehensive and fully referenced, this book is a must-read if you face the life-changing choices that come with kidney failure. |
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