Role of continuous renal replacement therapy in severe rhabdomyolysis with multiple organ failure due to methandriol abuse

Autori:

Sonja Škiljić, Gordana Kristek, Aurelija Majdenić Štaba, Ivana Haršanji Drenjančević, Nenad Nešković, Slavica Kvolik

Sažetak
Kontinuirane metode bubrežnoga nadomjesnog liječenja posljednjih godina imaju sve veću ulogu pri zbrinjavanju bolesnika u jedinicama intenzivnog liječenja. Prednosti koje one pružaju u odnosu prema konvencionalnim, intermitentnim metodama pogoduju kritično oboljelima, zbog čega je ova metoda vrlo privlačna pri izboru terapijskog pristupa u jedinicama intenzivnog liječenja. Primjer je klinički prikaz dotad zdravoga četrdesetšestogodišnjeg muškarca koji je primljen u jedinicu intenzivnog liječenja zbog iznenadno nastalog poremećaja stanja svijesti, respiratorne insuficijencije, cirkulacijske nestabilnosti, rabdomiolize, anurije i akutnoga bubrežnog oštećenja nepoznatog uzroka. Bolesnik je mehanički ventiliran, volumno resuscitiran, nalažući cirkulacijsku potporu vazopresorima. Unatoč inicijalno poduzetim mjerama intenzivnog liječenja nije došlo do oporavka diureze i hemodinamske stabilizacije uz daljnje pogoršanje stanja. Zbog perzistirajuće hiperkalemije opasne za život, metaboličke acidoze, uremije i rabdomiolize započeti su kontinuirano bubrežno nadomjesno liječenje (engl. Continuous renal replacement therapy – CRRT), uz istodobno pružanje potpore narušenim organskim sustavima, i traganje za mogućim uzrokom prezentirane kliničke slike. Nakon tjedan dana kontinuirane potpore narušenoj bubrežnoj funkciji došlo je do oporavka stanja svijesti, hemodinamske stabilizacije, odvajanja od strojne ventilacije i oporavka diureze uz normalizaciju bubrežne funkcije. Ciljanom toksikološkom analizom urina potvrđeno je da su anabolički steroidi koje je bolesnik uzimao mogući uzrok rabdomiolize i bubrežnog oštećenja. Bolesnik je desetog dana otpušten iz jedinice intenzivnog liječenja u dobrom općem stanju i uredne bubrežne funkcije. Kontinuirane metode bubrežnoga nadomjesnog liječenja učinkovit su način zbrinjavanja akutnoga bubrežnog oštećenja u kritično oboljelih zbog nastaloga multiorganskog zatajenja različite etiogeneze.
Summary

Continuous methods of renal replacement therapy (CRRT) in the treatment of acute kidney failure gained popularity in past years in the intensive care units. Compared to conventional methods (intermittent hemodialysis), they offer more hemodynamic stability, achievement of electrolytes and body fluids homeostasis, and have options for blood purification and controlling body temperature simultaneously. All these advantages make them the preferred method for the treatment of acute kidney injury in patients who are hemodynamically unstable with multiorgan failure from any cause. In this case report we describe a previously healthy 46–year-old man who came in the intensive care unit in the comatose state, hemodynamically unstable, with anuria and acute respiratory failure. The initial laboratory results showed rhabdomyolysis, acute renal failure, severe metabolic acidosis and hyperkalemia. According to the clinical examination and laboratory tests, he was critically ill with multiorgan failure and systemic inflammatory response syndrome due to an unknown trigger. Acute intoxication with an unknown substance was suspected. He was mechanically ventilated, with fluid resuscitation and high doses of vasopressors for the maintenance of perfusion pressures. Despite the initial treatment, hemodynamic instability, anuria and acute renal failure persisted with the worsening of clinical picture and control laboratory tests. We started continuous renal replacement therapy for seven days trying to find the cause for his clinical condition. Combination of heteroanamnesis with target toxicology diagnostic tests found that the use of anabolic steroids might have triggered rhabdomyolysis with acute renal failure. After few days he was fully awake, spontaneously breathing, circulatory stable with the return to normal renal function and diuresis. Control laboratory results returned to normal values. He was discharged from intensive care unit after ten days. Continuous methods of renal replacement therapy are a valuable method for the management of acute kidney failure in critically ill patients with hemodynamic instability and multiorgan failure from different causes.

Volumen: 1-2, 2020

Liječ Vjesn 2020;142:14–16

Preuzmi PDF