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A 60-year-old male with familial combined hyperlipidemia, ischemic heart disease and type 2 diabetes. Since childhood, intolerance to intense exercise. The patient was diagnosed of McArdle's disease after an episode of rhabdomyolysis associated with statins as treatment after a myocardial infarction. Since then, he had been treated with diet, fibrates and ezetimibe with good tolerance, despite this, LDL cholesterol (cLDL) remained >180mg/dl. He started to be treated with alirocumab 150mg/sc every 14 days, with excellent clinical response and a decrease in cLDL to 15mg/dl. Our case shows that PCSK9 inhibitors are effective and safe in patients with muscle diseases who have statin contraindication, and they are a good therapeutic tool for these patients., (Copyright © 2018 Sociedad Española de Arteriosclerosis. Publicado por Elsevier España, S.L.U. All rights reserved.)

Haemoglobin and myoglobin are haem proteins that play a key role as they help transport oxygen around the body. However, because of their chemical structure, these molecules can exert harmful effects when they are released massively into the bloodstream, as reported in certain pathological conditions associated with rhabdomyolysis or intravascular haemolysis. Once in the plasma, these haem proteins can be filtered and can accumulate in the kidney, where they become cytotoxic, particularly for the tubular epithelium, inducing acute kidney failure and chronic kidney disease. In this review, we will analyse the different pathological contexts that lead to the renal accumulation of these haem proteins, their relation to both acute and chronic loss of renal function, the pathophysiological mechanisms that cause adverse effects and the defence systems that counteract such actions. Finally, we will describe the different treatments currently used and present new therapeutic options based on the identification of new cellular and molecular targets, with particular emphasis on the numerous clinical trials that are currently ongoing., (Copyright © 2017 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

The purpose of this report is to emphasize the necessity to periodically explore internal environment variables, as certain metabolic alterations often go unnoticed during antipsychotic treatment. Early detection of such alterations may prevent catastrophic syndromes. We will also stress the clinical relevance of cognitive perseverations in schizophrenic patients, as these often condition habits of consumption which can alter the internal environment. In this clinical case of a schizophrenic patient, a chain of events led to a catastrophic syndrome: a trivial home accident (fall from own height) developed into a condition characterized by oligoanuria, hypokalemia, creatine phosphokinase (CPK) elevation (125,000 IU / L) and acute renal failure with dialysis requirement. This episode was non lethal due to the early implementation of support measures. We performed a revision of the available literature in order to discern the cause of the elevation of CPK. Here we aim to highlight the importance of 1) careful clinical and laboratory monitoring of psychopharmacological treatment, 2) interactions resulting from consumption habits capable of generating unforeseen consequences, 3) the role of the psychiatrist in the context of multidisciplinary work.

Acute kidney injury (AKI) is a growing concern in Intensive Care Units. The advanced age of our patients, with the increase in associated morbidity and the complexity of the treatments provided favor the development of AKI. Since no effective treatment for AKI is available, all efforts are aimed at prevention and early detection of the disorder in order to establish secondary preventive measures to impede AKI progression. In critical patients, the most frequent causes are sepsis and situations that result in renal hypoperfusion; preventive measures are therefore directed at securing hydration and correct hemodynamics through fluid perfusion and the use of inotropic or vasoactive drugs, according to the underlying disease condition. Apart from these circumstances, a number of situations could lead to AKI, related to the administration of nephrotoxic drugs, intra-tubular deposits, the administration of iodinated contrast media, liver failure and major surgery (mainly heart surgery). In these cases, in addition to hydration, there are other specific preventive measures adapted to each condition., (Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Rhabdomyolysis is a syndrome characterized by injure of skeletal muscle with the release of intracellular constituents into the circulation. Acute renal failure is a common complication and is the leading cause of morbidity and mortality in these patients. The most common aetiology is traumatisms, muscle compressions and extreme exertions. Most commonly, the cause of rhabdomyolysis is evident from the careful clinical history. Nevertheless, when the precipitant is not obvious the diagnosis is difficult and a raised clinical suspicion is required. We should investigate used medication or drugs, infections, electrolyte abnormalities and a number of inherited enzyme deficiencies, in which cases the muscle is unable to use available energy. We report two clinical cases of acute renal failure due to rhabdomyolysis by metabolic myopathies due to a carnitine palmitoyltransferase deficiency on the one hand and by myophosphorylase deficiency on the other. We describe their clinical features and progress.

Rhabdomyolysis is a clinical syndrome characterized by the breakdown and later necrosis of skeletal muscle, leading to the release of various intracellular components into the blood stream. The clinical expression of rhabdomyolysis ranges from asymptomatic to severe forms involving multiorgan failure with electrolyte imbalance, respiratory distress syndrome, acute renal failure and disseminated intravascular coagulation. Diagnosis is based on a finding of elevated serum levels of components that are normally found within the muscle cell, chiefly muscle enzymes and myoglobin. Acute kidney failure, one of the main consequences of rhabdomyolysis, occurs in 4% to 33% of cases. Treatment requires prompt volume replacement with crystalloids. In spite of successful resuscitation and prophylaxis against myoglobulin-induced renal failure, 1 out of every 3 patients develops kidney damage and requires continuous replacement therapy.

Renal failure secondary to effort rhabdomyolysis is uncommon. We report three males age 28, 37 (military sportsmen) and 44 years (sedentary obese), with this condition. Episodes occurred after a training session to run a triathlon, during the course of a mini marathon and during a rescue attempt of a drowning person. All three subjects experienced intense muscle symptoms, hemoglubinuria, oliguria, rise of blood urea nitrogen and a significant rise in muscle enzymes. Creatinekinase reached a maximum of 41 times normal, aspartate aminotransferase a maximum 35 times normal and lactacte dehydrogenase a maximum of 11 times normal. There was a rapid elevation of serum creatinine, reaching values of 6.6 and 9.8 mg/dl on the third day after the physical effort. This parameter had a disproportionate elevation in relation to urea nitrogen, in two subjects. All subjects were managed with saline hydration, sodium bicarbonate and furosemide. Only one required hemodialysis for two days. All normalized their renal function 18 to 48 days after the physical exertion. No subject had other predisposing conditions for acute renal failure.

Hemoglobin and myoglobin heme pigments and iron have acute and chronic nephrotoxic effects, which are often associated with massive hemolysis and rhabdomyolysis. We report a patient with a myelodysplastic syndrome and paroxysmal nocturnal hemoglobinuria phenotype who developed an acute renal failure after a severe haemolytic crisis. There was not evidence of renal vascular pathology, urinary tract obstruction or prerenal factors. Renal biopsy showed features of acute tubular necrosis, with extended iron deposits in tubule cell cytoplasm and tubulo-interstitial fibrosis and atrophy. The patient was oliguric requiring hemodialisys during three weeks, recovering renal function on the fourth week after admission. This case underlines the nephrotoxic role of heme pigment and iron, and possible pathophysiologic mechanisms involved in acute and chronic toxicity of both agents are reviewed.

Statins are competitive inhibitors of hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) reductase and are the most commonly used drugs to treat hyperlipidaemia. Muscle toxicity is an adverse effect reported with a low incidence and rarely associated with acute renal failure due to rhabdomyolysis. We describe two patients with chronic renal failure treated with pravastatin and simvastatin who suffered rhabdomyolysis and acute renal failure. One patient started pravastatin several days after cessation of bezafibrate and developed acute renal failure without needing dialysis. The other was treated with simvastatin three years ago and suffered rhabdomyolysis when renal function was impaired after indomethacin was prescribed for backache. He needed hemodialysis because of acute cardiac failure and died from a respiratory infection while on mechanical ventilation. Myopathy was reversible in both patients. We recommend starting statins with the lower doses in chronic renal failure and monitoring muscle enzymes when renal function changes or when new drugs with potential interactions are prescribed.

Introduction: The prognosis of rhabdomyolysis is conditioned by the development of acute renal failure which depends of quick preventive measures. Rhabdomyolysis is diagnosed by measuring plasma creatinkinase and it is usually suspected by the presence of previous putative causal factors like traumatisms. Non traumatic rhabdomyolysis usually lacks of clinical relevant antecedents and the syndrome should be suspected by patient clinical symptomatology; unfortunately, this one has been scarcely studied., Objectives: To describe the semiology observed in patients experiencing non traumatic rhabdomyolysis and to identify which symptoms induced to the subject to go to the emergency room in order to facilitate the diagnostic procedure., Patients and Methods: We studied the patients with non traumatic rhabdomyolysis (creatinkinase > 1,000 IU/l) which attended the emergency room in a one year period. We collected data regarding their clinical symptomatology as well as which of them was responsible of his/her coming to the emergency unit. Symptoms were classified in four groups: muscular, urinary, neurological and others., Results: We evaluated 49 patients. The relative frequency of each kind of symptoms was the following: muscular 51%, urinary 18%, neurological 67%, and others 47%. The absolute frequency of the symptoms which caused the consultation were: muscular 16%, urinary 2%, neurological 48%, others 22%, muscular and neurological associated 6%, and neurological and other associated 6%., Conclusion: CK serum levels should be measured in all of the patients attending the emergency unit who exhibit some type of neurological manifestation.

Background: To investigate the characteristics of medical rhabdomyolysis (RM) in the elderly, as well as differences compared with those observed in younger patients., Patients and Methods: Prospective study of 56 elderly patients (> or = 65 years) with RM and 73 younger patients (> 7 years and < 65 years) with RM for 43 months. The RM characteristics were analyzed in the elderly group (ERM) and compared with those in the younger group (YRM)., Results: Fifty-six elderly patients with RM (38 males and 18 females, with a mean age of 76.3 +/- 7.6 years; range: 65-92 years) and 73 younger patients (57 males and 16 females, with a mean age of 37.9 +/- 15.6 years; range: 13-63 years), made up the 129 patients in the study. The most common cause for RM in the ERM was muscle compression due to immobilization and the multicausative group, both with 9 (16%) cases, followed by respiratory infection with 8 (14.2%) cases. In the YRM, the most common cause was physical exertion with 15 patients (20.5%) and multicausative with 18 patients (24.6%). Myalgia predominated in the YRM group, with 25 vs. 9 (odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.0-7.3; p < 0.05). Acute renal failure (ARF) occurred in 13 patients in the ERM group compared with 4 in the YRM group (OR: 5.2; 95% CI: 1.4-23; p < 0.01). In the logistic regression analysis an association was found between hypoalbuminemia and ARF for the ERM group. In the presence of ARF, both ERM and YRM had decreased serum calcium levels, deeper in YRM and more prolonged in the ERM. Six patients in the ERM died, and four of them had developed ARF. In contrast, none of the two deceased patients in the YRM had the complication of ARF., Conclusion: Almost half of cases of RM occur in elderly patients, which is mostly due to muscle compression and infections, particularly in the respiratory tract. Symptoms are usually mild and the development of ARF is more common than in younger patients, and its presence is associated with hypoalbuminemia. Hypocalcemia associated with ARF was less deep in the elderly, but more persistent than in younger patients. Most deceased patients in the elderly group previously developed ARF.

Background: The aim of this study was to determine the causes of non traumatic or medical rhabdomyolysis (RM) and analyze the clinical and biologic characteristics, as well as the predictive factors of acute renal failure (ARF)., Methods: Fifty-nine patients with RM admitted to the Internal Medicine Department over an 18-month period were prospectively studied. The patients were classified into etiologic groups. Anamnesis, physical exploration and general analytical studies including creatinkinase, myoglobin, aldolase, magnesium and proteinogram were performed. Urine sodium was determined in patients with ARF>, Results: Myalgias in 14 patients (23.7%) and a decrease in strength in 11 patients (18.6%) were the main clinical manifestations observed. As a sole cause, convulsion was the most frequent manifestation in 11 patients (18.6%) followed by muscular compression in 10 patients (16.9%). In the plurietiologic group the most frequent manifestation was muscular compression in 5 patients (16.9%) followed by alcoholism in 4 patients (6.7%). No differences were found in either the clinical manifestation or the biology of the RM among the different etiologies. Eight patients presented ARF (13.5%) with one patient requiring dialysis, and good response being observed with conservative treatment in 5 patients. On multivariant analysis the statistically significant ARF predictive factors were: age over 70 years (p = 0.003), nonketotic hyperosmolar diabetic coma (p = 0.01), previous dehydration (p = 0.001) and initial uric acid levels greater than or equal to 6 mg/dl (p = 0.002)., Conclusions: The clinical expression of rhabdomyolysis was small with the most frequent manifestations being convulsions and muscular compression. The predictive factors for acute renal failure were advanced age, nonketotic hyperosmolar diabetic coma, dehydration, and hyperuricemia.

Rhabdomyolysis was evaluated by measurement of total creatine kinase (CK) and lactic dehydrogenase (LDH) in 19 patients with severe sepsis; 12 developed acute renal failure (Group B) and 7 did not (Group A). Results were compared to 7 patients with trauma (Group C) and 6 patients with chronic renal failure and minor infections (Group D). CK was higher (p less than 0.005) in Group B than in A. Results in Group C were similar to those in A. Elevation of CK correlated to increases in creatinine (r = 0.655, p less than 0.005). CK levels of Group D patients were lower than those of Group B. Blood pressure, lactate and pO2 were similar in both groups but thrombopenia was noted in Group B patients. Our results suggest that rhabdomyolysis and thrombopenia play a role in the development of renal failure in patients with severe sepsis.