Rhabdomyolysis - Myoglobin - Dialysis

2/04/2008

Question:  Is dialysis an effective method for clearing myoglobin from the blood in patients with rhabdomyolysis?

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<1>

Unique Identifier [PMID]: 17430315

Authors: Peltonen S. Ahlstrom A. Kylavainio V. Honkanen E. Pettila V.

Institution: Division of Nephrology, Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland.

Title: The effect of combining intermittent hemodiafiltration with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis.

Source: Acta Anaesthesiologica Scandinavica. 51(5):553-8, 2007 May.

Abstract: BACKGROUND: Our aim was to examine the effect of combining intermittent hemodiafiltration (HDF) with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis. METHODS: This was a prospective, randomized, controlled, cross-over study. Sixteen rhabdomyolysis patients with plasma myoglobin concentrations above 10,000 microg/l were randomized. Forced alkaline diuresis was started immediately after allocation and continued throughout the study. HDF, which lasted for 4 h, was started in group A immediately after allocation and in group B 4 h later. The primary analysis was intention-to-treat by repeated measures analysis of variance and Mann-Whitney U-test. RESULTS: The percentage elimination of myoglobin from the circulation during HDF differed significantly from that during alkaline diuresis (28.1% vs. 14.2%, respectively; P < 0.01). The mean decrease in plasma myoglobin concentration during HDF [9731 microg/l; 95% confidence interval (CI), 3672-5345 microg/l] and forced alkaline diuresis (3646 microg/l; 95% CI, 1260-6032 microg/l) did not show a statistically significant difference (P= NS). The mean total amount of myoglobin found in the ultrafiltrate was 58.4 mg. CONCLUSION: The percentage myoglobin decrease during combined HDF and forced alkaline diuresis was higher than that during forced alkaline diuresis alone. Renal replacement therapy with filtration techniques may be considered for the clearance of myoglobin from plasma when urine alkalinization is not successful.

Publication Type: Journal Article. Randomized Controlled Trial.
 

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Unique Identifier [PMID]: 15954972

Authors: Mikkelsen TS. Toft P.

Institution: Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark.

Title: Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis.

Source: Acta Anaesthesiologica Scandinavica. 49(6):859-64, 2005 Jul.

Abstract: BACKGROUND: (I) To investigate the kinetics of the myoglobin and creatine kinase (CK) in rhabdomyolysis. Especially to describe those patients in whom an isolated increase in the myoglobin or the CK occurred at a later stage. (II) To evaluate the sensitivity of the myoglobin and the CK as prognostic tools for the development of Acute renal failure (ARF). (III) To investigate the effect of continuous venovenous haemodiafiltration (CVVHDF) on the myoglobin elimination in ARF. PATIENTS AND METHODS: Prospective and retrospective cohort study carried out in an ICU of a university hospital. A total of 47 critically ill patients with rhabdomyolysis and a plasma myoglobin > 5000 microg l(-1) were admitted between July 1998 and July 2003. RESULTS: (I) The myoglobin peaked 0.66 +/- 0.6 days before the CK. The elimination kinetics of the myoglobin was faster than for the CK. (II) Fifty percent developed ARF. Mortality in the ARF patients was 52% compared to 14% in the non-ARF patients. The sensitivity and specificity of developing ARF were higher with the myoglobin in comparison to the CK. (III) In non-ARF, t(1/2) CK was 25.5 h and t(1/2) myoglobin was 17 h (13-23). In those with ARF treated with CVVHDF, t(1/2) CK was 24.8 and t(1/2) myoglobin was 21 h (17-29). CONCLUSION: (I) The myoglobin peaked earlier than the CK. (II) The myoglobin was a better prognostic tool than the CK. However, the myoglobin also has a wide interindividual range. (III) Though the myoglobin is eliminated in ultrafiltration t(1/2) myoglobin, it was not faster in patients with ARF treated with CVVHDF compared to non-ARF patients.

Publication Type: Journal Article.
 

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Unique Identifier [PMID]: 15774064

Authors: Ronco C.

Institution: Department of Nephrology, St Bortolo Hospital, Vicenza, Italy. cronco@goldnet.it

Title: Extracorporeal therapies in acute rhabdomyolysis and myoglobin clearance.[comment].

Source: Critical Care (London, England). 9(2):141-2, 2005 Apr.

Abstract: Rhabdomyolysis is a pathogenetic cause of acute kidney injury. In such circumstances, not only should therapeutic strategies to replace the failing kidney be implemented, but measures should also be explored to prevent further damage by circulating myoglobin. Volume expansion and forced diuresis have been used, but when a kidney fails, renal replacement therapies are instituted. The techniques and devices used for classic dialytic techniques have displayed a limited capacity for the removal of circulating myoglobin. In a recent paper, Naka and colleagues have proposed the use of a super-high-flux membrane in continuous hemofiltration. The removal of myoglobin was greater than in than any previous report. Thus, if the removal of myoglobin is desirable, a combination of continuous hemofiltration and hyperpermeable membranes seems to be the most effective. However, care must be exercised to prevent unwanted albumin losses.

Publication Type: Comment. Comparative Study. Journal Article.
 

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Unique Identifier [PMID]: 15774055

Authors: Naka T. Jones D. Baldwin I. Fealy N. Bates S. Goehl H. Morgera S. Neumayer HH. Bellomo R.

Institution: Department of Intensive Care, Melbourne University, Austin Hospital, Melbourne, Australia.

Title: Myoglobin clearance by super high-flux hemofiltration in a case of severe rhabdomyolysis: a case report.[see comment].

Source: Critical Care (London, England). 9(2):R90-5, 2005 Apr.

Abstract: OBJECTIVE: To test the ability of a novel super high-flux (SHF) membrane with a larger pore size to clear myoglobin from serum. SETTING: The intensive care unit of a university teaching hospital. SUBJECT: A patient with serotonin syndrome complicated by severe rhabodomyolysis and oliguric acute renal failure. METHOD: Initially continuous veno-venous hemofiltration was performed at 2 l/hour ultrafiltration (UF) with a standard polysulphone 1.4 m2 membrane (cutoff point, 20 kDa), followed by continuous veno-venous hemofiltration with a SHF membrane (cutoff point, 100 kDa) at 2 l/hour UF, then at 3 l/hour UF and then at 4 l/hour UF, in an attempt to clear myoglobin. RESULTS: The myoglobin concentration in the ultrafiltrate at 2 l/hour exchange was at least five times greater with the SHF membrane than with the conventional membrane (>100,000 microg/l versus 23,003 microg/l). The sieving coefficients with the SHF membrane at 3 l/hour UF and 4 l/hour UF were 72.2% and 68.8%, respectively. The amount of myoglobin removed with the conventional membrane was 1.1 g/day compared with 4.4-5.1 g/day for the SHF membrane. The SHF membrane achieved a clearance of up to 56.4 l/day, and achieved a reduction in serum myoglobin concentration from >100,000 microg/l to 16,542 microg/l in 48 hours. CONCLUSIONS: SHF hemofiltration achieved a much greater clearance of myoglobin than conventional hemofiltration, and it may provide a potential modality for the treatment of myoglobinuric acute renal failure.

Publication Type: Case Reports. Comparative Study. Journal Article.
 

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Unique Identifier [PMID]: 12200811

Authors: Maduell F. Navarro V. Cruz MC. Torregrosa E. Garcia D. Simon V. Ferrero JA.

Institution: Department of Nephrology, Hospital General de Castellon, Spain. fmaduellc@senefro.org

Title: Osteocalcin and myoglobin removal in on-line hemodiafiltration versus low- and high-flux hemodialysis.

Source: American Journal of Kidney Diseases. 40(3):582-9, 2002 Sep.

Abstract: BACKGROUND: Removal of medium and large solutes is poor with low-flux (LF-HD) and limited with high-flux hemodialysis (HF-HD) and on-line hemodiafiltration (OL-HDF). In clinical practice, there are few in vivo solute markers. Osteocalcin is a protein with a molecular mass of 5,800 daltons, and myoglobin is a large molecule with a molecular mass of 17,200 daltons. The aim of this study was to evaluate the impact of OL-HDF on in vivo removal of a wide spectrum of solutes (urea, creatinine, osteocalcin, beta2-microglobulin, and myoglobin) in comparison to LF-HD and HF-HD. METHODS: Twenty-three patients (15 men, 8 women) were studied. Every patient underwent three dialysis sessions with routine HD parameters. We compared 1.8-m2 polysulfone LF-HD and 1.8-m2 polysulfone HF-HD versus OL-HDF. Predialysis and postdialysis solute concentrations were measured. The percentage of reduction ratio for each solute was calculated. RESULTS: Mean values for predialysis osteocalcin, beta2-microglobulin, and myoglobin were 16.3 +/- 21 ng/mL, 27.4 +/- 5 mg/L, and 239 +/- 162 ng/mL in LF-HD, respectively. Urea and creatinine reduction ratios were similar in LF-HD and HF-HD and only 1.2% higher in OL-HDF. Osteocalcin, beta2-microglobulin, and myoglobin reduction ratios for LF-HD were negligible. Mean osteocalcin reduction rates were 54.2% +/- 12% for HF-HD versus 63.5% +/- 9% for OL-HDF (reinfusion volume, 26.8 +/- 5 L/session; P < 0.01). Mean beta2-microglobulin reduction rates were 60.1% +/- 9% for HF-HD versus 75.4% +/- 9% for OL-HDF (P < 0.01). Mean myoglobin reduction rates were 24.5% +/- 6% and 62.7% +/- 9% for HF-HD and OL-HDF, respectively (P < 0.01). CONCLUSION: LF-HD does not seem to remove solutes with a molecular weight greater than 5,800 daltons. OL-HDF provides marked enhancement of convection volume and enables a significant increase in osteocalcin and beta2-microglobulin removal. Myoglobin extraction is nil with LF-HD, very low with HF-HD, and only adequate with OL-HDF. Copyright 2002 by the National Kidney Foundation, Inc.

Publication Type: Comparative Study. Journal Article.
 

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Unique Identifier [PMID]: 10551978

Authors: Amyot SL. Leblanc M. Thibeault Y. Geadah D. Cardinal J.

Institution: Departments of Intensive Care, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada.

Title: Myoglobin clearance and removal during continuous venovenous hemofiltration.

Source: Intensive Care Medicine. 25(10):1169-72, 1999 Oct.

Abstract: Myoglobin has a relatively high molecular weight of 17,000 Da and is poorly cleared by dialysis (diffusion). However, elimination of myoglobin might be enhanced by an epuration modality based on convection for solute clearances. We present a single case of myoglobin-induced renal failure (peak creatine kinase level: 313,500 IU/l) treated by continuous venovenous hemofiltration (CVVH). Our purpose was to evaluate the efficiency of such a modality using an ultrafiltration rate of 2 to 3 l/h for myoglobin removal and clearance. The hemofilter was a 0.9 m(2) polyacrylonitrile (AN69) membrane Multiflow-100 (Hospal-Gambro, St-Leonard, Canada) and the blood flow rate was maintained at 150 ml/min by an AK-10 pump (Hospal-Gambro, St-Leonard, Canada). The ultrafiltration bag was placed 60 cm below the hemofilter and was free of pump control or suction device. Serum myoglobin concentration was 92,000 microg/l at CVVH initiation and dropped to 28,600 microg/l after 18 h of the continuous modality. The mean sieving coefficient for myoglobin was 0.6 during the first 9 h of therapy and this decreased to 0.4 during the following 7 h. Mean clearance of myoglobin was 22 ml/min, decreasing to 14 ml/min during corresponding periods, while the mean ultrafiltration rates were relatively stable at 2,153 +/- 148 ml/h and 2,074 +/- 85 ml/h, respectively. In contrast to myoglobin, the sieving coefficeint for urea, creatinine, and phosphorus remained stable at 1.0 during the first 16 h of CVVH. More than 700 mg of myoglobin were removed by CVVH during the entire treatment. In conclusion, considerable amounts of myoglobin can be removed by an extracorporeal modality allowing important convective fluxes and middle molecule clearances, such as CVVH at a rate of 2 to 3 l/h using an AN69 hemofilter. If myoglobin clearance had been maintained at 22 ml/min, 32 l of serum would have been cleared per day. However, the sieving coefficient of myoglobin decreased over time, probably as a consequence of protein coating and/or blood clotting of the hemofilter. Whereas myoglobin can be removed by CVVH, it remains unknown at this point if such a modality, applied early, can alter or shorten the course of myoglobinuric acute renal failure.

Publication Type: Case Reports. Journal Article.
 

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Unique Identifier [PMID]: 9306377

Authors: Bastani B. Frenchie D.

Title: Significant myoglobin removal during continuous veno-venous haemofiltration using F80 membrane.

Source: Nephrology Dialysis Transplantation. 12(9):2035-6, 1997 Sep.

Publication Type: Case Reports. Letter.
 

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Unique Identifier [PMID]: 8201089

Authors: Wakabayashi Y. Kikuno T. Ohwada T. Kikawada R.

Institution: Department of Medicine, University of Kitasato Medical School, Sagamihara, Japan.

Title: Rapid fall in blood myoglobin in massive rhabdomyolysis and acute renal failure.

Source: Intensive Care Medicine. 20(2):109-12, 1994.

Abstract: OBJECTIVE: Myoglobin kinetics of removal from the circulation were studied in patients following massive rhabdomyolysis, to see if myoglobin remains for long in the circulation in the anuric state and if myoglobin elimination was affected by therapeutic manipulation such as haemofiltration or haemodialysis. DESIGN: Randomised and controlled study. SETTING: Intensive care unit of a tertiary care teaching hospital. PATIENTS: 26 patients of rhabdomyolysis whose serum myoglobin exceeded more than 500 nmol/l. Thirteen patients developed acute renal failure and underwent treatment with blood purification (Group HD). The remaining 13 patients did not require treatment with blood purification (control subjects, Group non-HD). INTERVENTIONS: In patients of group HD, twelve were treated with haemofiltration and/or haemodialysis. One was treated with peritoneal dialysis. The patient of group non-HD were treated with fluid infusion alone. MEASUREMENTS AND RESULTS: The serum concentrations of myoglobin were serially determined. The highest levels of myoglobin was 1641 +/- 484 nmol/l (mean +/- SEM) in the group non-HD and were 8957 +/- 2300 in the group HD. In the group non-HD, the blood myoglobin fell exponentially once myoglobin release into the circulation ceased. This was also noted in the group HD. The exponential decrease was observed even on the days when the patient passed little urine or treatment with blood purification was not performed. CONCLUSION: In patients with massive myoglobinaemia, the blood myoglobin rapidly fell independent of renal function or any therapeutic manipulation. The results indicate that extrarenal factors played a major role in disposing circulating myoglobin in such patients.

Publication Type: Clinical Trial. Journal Article. Randomized Controlled Trial.
 

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Unique Identifier [PMID]: 8294158

Authors: Stefanovic V. Bogicevic M. Mitic M.

Institution: Institute of Nephrology and Hemodialysis, Faculty of Medicine, Nis, Yugoslavia.

Title: Myoglobin elimination in end stage kidney disease patients on renal replacement treatment.

Source: International Journal of Artificial Organs. 16(9):659-61, 1993 Sep.

Abstract: Increased serum myoglobin levels were previously found in patients with chronic renal failure. In this report we have studied the effects of dialysis on myoglobin elimination in patients on CAPD, IPD, cuprophan and polyacrylonitrile (PAN) membrane hemodialysis. Peritoneal dialysis removed a significant amount of myoglobin, CAPD 480 +/- 65 micrograms/day, IPD 270 +/- 25 micrograms/12 h treatment, while with cuprophan dialysis none, and with PAN dialysis only an insignificant amount of myoglobin. The serum myoglobin levels were 250 +/- 18 and 264 +/- 14 micrograms/l on cuprophan and a 3 month dialysis on PAN membrane, respectively. Markedly increased serum levels were also found in CAPD and IPD patients on peritoneal dialysis, 227 +/- 25 and 286 +/- 32 micrograms/l respectively. This study has shown that there is an increased serum myoglobin concentration in end-stage kidney disease patients on dialysis. Although peritoneal membrane is permeable to myoglobin, a relatively small amount is removed, and the serum level in CAPD and IPD patients was not significantly different from the serum myoglobin concentration in hemodialysis patients. Furthermore myoglobin could not be removed by hemodialysis membrane and an analysis of its important extrarenal catabolism level points were analyzed.

Publication Type: Journal Article.
 

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Unique Identifier [PMID]: 1424305

Authors: Feinfeld DA. Cheng JT. Beysolow TD. Briscoe AM.

Institution: Department of Medicine, Harlem Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10037.

Title: A prospective study of urine and serum myoglobin levels in patients with acute rhabdomyolysis.

Source: Clinical Nephrology. 38(4):193-5, 1992 Oct.

Abstract: Serum and urine myoglobin levels, measured by radioimmunoassay, were determined prospectively in eight patients with acute rhabdomyolysis, within 24 hours of admission. Five patients had urine myoglobin concentrations greater than 1,000 ng/ml (normal < 5 ng/ml); four of these patients subsequently developed acute renal failure. In three patients whose urinary myoglobin levels ranged from 19 to 275 ng/ml, acute renal failure did not occur. This difference in the occurrence of acute renal failure between the two patient groups was statistically significant (p < 0.05). Mean peak serum creatinine was significantly higher in the patients with high urine myoglobin (6.4 +/- 1.3 mg/dl) compared to those with low urine myoglobin (2.2 +/- 0.3 mg/dl), p < 0.02. There was no statistical correlation between level of serum creatine phosphokinase and serum or urine myoglobin, although the serum and urine myoglobin levels correlated well with each other. These findings suggests that among other factors, urine myoglobin may need to reach a critical level in order for myoglobinuric renal failure to ensue.

Publication Type: Journal Article.
 

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Unique Identifier [PMID]: 7140026

Authors: Hart PM. Feinfeld DA. Briscoe AM. Nurse HM. Hotchkiss JL. Thomson GE.

Title: The effect of renal failure and hemodialysis on serum and urine myoglobin.

Source: Clinical Nephrology. 18(3):141-3, 1982 Sep.

Abstract: In 33 patients with chronic renal disease, the concentration of myoglobin in serum and urine was found to be significantly elevated over that of normal controls. Hemodialysis had no statistically significant effect in lowering the serum myoglobin of patients with end stage renal disease. Similarly, no difference was found in serum myoglobin in blood entering and leaving the dialysis coil. Since myoglobin was not detectable in the dialyzate, these data illustrate that myoglobin is not appreciably dialyzable. The association between chronic renal failure and high concentration of serum and urine myoglobin was confirmed. These abnormally high levels of myoglobin in serum and urine do not necessarily lead to myoglobinuric renal failure.

Publication Type: Journal Article.