RİSK ALTINDAKİ BÖBREK: EZİLME SENDROMUNA BAĞLI AKUT BÖBREK HASARI

Ezilme sendromu, depremler veya diğer yıkıcı afetlerde ölümün ikinci en yaygın nedenidir. Ezilmeyle ilişkili akut böbrek hasarı (ABH), ezilme sendromunun en önemli bileşenidir. Bu nedenle, sağlık profesyonellerinin patofizyoloji, klinik ve laboratuvar özellikleri, komplikasyonlar ve tedavi hakkında bilgi sahibi olmaları büyük öneme haizdir. Ezilme yaralanmalarına ikincil gelişen ABH'nin patogenezi çok yönlüdür. Kompartman sendromuna bağlı hipovolemi ve renal hipoperfüzyon, iskemik akut tübüler nekroza yol açabilen başlıca mekanizmadır. Ayrıca, miyoglobinüri miyoglobin tıkaçlarının ve doğrudan tübüler toksisitenin oluşumuna neden olabilir. Oksidatif hasar, artmış sitokin düzeyleri ve diğer faktörler de patogeneze katkıda bulunabilir. Ezilme sendromu, ciddi elektrolit dengesizlikleri, sepsis ve kanama gibi durumları tetikleyebilir ve bu durum ABH'yi daha da kötüleştirebilir. Erken tanı ve uygun tedavi, agresif hidrasyon ve elektrolit dengesinin yönetimi gibi faktörler, renal hasarı önlemeye veya en aza indirmeye yardımcı olabilir. Bu derleme, ezilme sendromu bağlamında ABH'nin patofizyolojisi, komplikasyonları ve tedavisi hakkında bir genel bakış sunmaktadır.

Anahtar Kelimeler:

Ezilme sendromu, akut böbrek hasarı, rabdomiyoliz

THE KIDNEY AT RISK: UNDERSTANDING CRUSH SYNDROMERELATED ACUTE KIDNEY INJURY

Crush syndrome (systemic manifestations of traumatic rhabdomyolysis) is the second leading cause of death after earthquakes or other destructive disasters. Crush-related acute kidney injury (AKI) is the most important component of crush syndrome, and medical professionals living in disaster-prone regions should know about its pathophysiology, clinical and laboratory features, complications, and treatment. Pathogenesis of AKI on the basis of crush injuries is multifaceted. The most important mechanism is compartment syndrome-related hypovolemia, and consequent renal hypoperfusion, which may result in ischemic acute tubular necrosis. Also, rhabdomyolysis-related myoglobinuria may result in the formation of kidney-damaging myoglobin casts and direct tubular toxicity. Formation of uric acid plugs, oxidant injury, increased serum levels of cytokines, and still many other factors may take a role in the pathogenesis as well. Crush syndrome can cause serious electrolyte imbalances, sepsis, and bleeding, which can further exacerbate AKI. Early recognition and appropriate management, which includes aggressive hydration and management of electrolyte imbalances can help to prevent or minimize kidney damage. This review provides an overview of the pathophysiology, complications, and treatment of AKI in the context of crush syndrome.

Keywords:

Crush syndrome, acute Kidney injury, rhabdomyolysis,

PDF

___

1. Vanholder R, Sever MS, Erek E, Lameire N. Acute renal failure related to the crush syndrome: towards an era of seismo-nephrology? Nephrol Dial Transplant 2000;15(10):1517-21. [CrossRef] google scholar
2. Better OS, Abassi Z, Rubinstein I, Marom S, Winaver Y, Silberman M. The mechanism of muscle injury in the crush syndrome: ischemic versus pressure-stretch myopathy. Miner Electrolyte Metab 1990;16(4):181-4. google scholar
3. Sharma R. Gujarat earthquake causes major mental health problems. Bmj 2002;324(7332):259. [CrossRef] google scholar
4. Shoaf KI, Sareen HR, Nguyen LH, Bourque LB. Injuries as a result of California earthquakes in the past decade. Disasters 1998;22(3):218-35. [CrossRef] google scholar
5. Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, Ergin H, et al. Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake. Nephrol Dial Transplant 2002;17(11):1942-9. [CrossRef] google scholar
6. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol 2000;11(8):1553-61. [CrossRef] google scholar
7. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982;61(3):141-52. [CrossRef] google scholar
8. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988;148(7):1553-7. [CrossRef] google scholar
9. Tanaka H, Oda J, Iwai A, Kuwagata Y, Matsuoka T, Takaoka M, et al. Morbidity and mortality of hospitalized patients after the 1995 Hanshin-Awaji earthquake. Am J Emerg Med 1999;17(2):186-91. [CrossRef] google scholar
10. Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006;354(10):1052-63. [CrossRef] google scholar
11. Sheng ZY. Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. J Trauma 1987;27(10):1130-5. [CrossRef] google scholar
12. Sever MS, Erek E, Vanholder R, Akoğlu E, Yavuz M, Ergin H, et al. The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. Kidney Int 2001;60(3):1114-23. [CrossRef] google scholar
13. Vanholder R, Sükrü Sever M, Lameire N. Kidney problems in disaster situations. Nephrol Ther 2021;17s:S27-36. [CrossRef] google scholar
14. Noji EK. Prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990;323(8):550-1. [CrossRef] google scholar
15. Goldfarb DS, Chung S. The absence of rhabdomyolysis-induced renal failure following the World Trade Center collapse. Am J Med 2002;113(3):260. [CrossRef] google scholar
16. Sever MS, Erek E, Vanholder R, Koc M, Yavuz M, Ergin H, et al. Treatment modalities and outcome of the renal victims of the Marmara earthquake. Nephron 2002;92(1):64-71. [CrossRef] google scholar
17. Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, et al. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997;42(3):470-6. [CrossRef] google scholar
18. Hatamizadeh P, Najafi I, Vanholder R, Rashid-Farokhi F, Sanadgol H, Seyrafian S, et al. Epidemiologic aspects ofthe Bam earthquake in Iran: the nephrologic perspective. Am J Kidney Dis 2006;47(3):428-38. [CrossRef] google scholar
19. Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990;322(12):825-9. [CrossRef] google scholar
20. Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med 1999;164(5):366-9. [CrossRef] google scholar
21. Better OS. The crush syndrome revisited (1940-1990). Nephron 1990;55(2):97-103. [CrossRef] google scholar
22. Sever MS, Vanholder R. Management of crush syndrome casualties after disasters. Rambam Maimonides Med J 2011;2(2):e0039. [CrossRef] google scholar
23. Zager RA. Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int. 1996;49(2):314-26. [CrossRef] google scholar
24. Lopez JR, Linares N, Cordovez G, Terzic A. Elevated myoplasmic calcium in exercise-induced equine rhabdomyolysis. Pflugers Arch 1995;430(2):293-5. [CrossRef] google scholar
25. Holt S, Moore K. Pathogenesis of renal failure in rhabdomyolysis: the role of myoglobin. Exp Nephrol 2000;8(2):72-6. [CrossRef] google scholar
26. Wang L, Hong S, Huang H, Yang M. Rhabdomyolysis following status epilepticus with hyperuricemia: A case report and literature review. Medicine (Baltimore) 2018;97(26):e11281. [CrossRef] google scholar
27. Shimazu T, Yoshioka T, Nakata Y, Ishikawa K, Mizushima Y, Morimoto F, et al. Fluid resuscitation and systemic complications in crush syndrome: 14 Hanshin-Awaji earthquake patients. J Trauma 1997;42(4):641-6. [CrossRef] google scholar
28. Anderson RJ, Linas SL, Berns AS, Henrich WL, Miller TR, Gabow PA, et al. Nonoliguric acute renal failure. N Engl J Med 1977;296(20):1134-8. [CrossRef] google scholar
29. Poels PJ, Gabreels FJ. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg 1993;95(3):175-92. [CrossRef] google scholar
30. Veenstra J, Smit WM, Krediet RT, Arisz L. Relationship between elevated creatine phosphokinase and the clinical spectrum of rhabdomyolysis. Nephrol Dial Transplant 1994;9(6):637-41. [CrossRef] google scholar
31. Mikkelsen TS, Toft P. Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis. Acta Anaesthesiol Scand 2005;49(6):859-64. [CrossRef] google scholar
32. Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol. N Engl J Med 1981;305(3):117-23. [CrossRef] google scholar
33. Akmal M, Bishop JE, Telfer N, Norman AW, Massry SG. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. J Clin Endocrinol Metab 1986;63(1):137-42. [CrossRef] google scholar
34. Gunal AI, Celiker H, Dogukan A, Ozalp G, Kirciman E, Simsekli H, et al. Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes. J Am Soc Nephrol 2004;15(7):1862-7. [CrossRef] google scholar
35. Ron D, Taitelman U, Michaelson M, Bar-Joseph G, Bursztein S, Better OS. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984;144(2):277-80. [CrossRef] google scholar
36. Sever MS, Sever L, Vanholder R. Disasters, children and the kidneys. Pediatr Nephrol 2020;35(8):1381-93. [CrossRef] google scholar
37. Vanholder R, Sever MS, De Smet M, Erek E, Lameire N. IIntervention of the renal disaster relief task force in the 1999 Marmara, Turkey earthquake. Kidney Int 2001;59(2):783-91. [CrossRef] google scholar
38. Sever MS, Vanholder R. Management of crush victims in mass disasters: highlights from recently published recommendations. Clin J Am Soc Nephrol 2013;8(2):328-35. [CrossRef] google scholar
39. Zager RA. Studies of mechanisms and protective maneuvers in myoglobinuric acute renal injury. Lab Invest 1989;60(5):619-29. google scholar
40. Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma 2004;56(6):1191-6. [CrossRef] google scholar
41. Sever MS, Vanholder R. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant 2012;27Suppl1:i1-67. [CrossRef] google scholar
42. Vanholder R, Borniche D, Claus S, Correa-Rotter R, Crestani R, Ferir MC, et al. When the earth trembles in the Americas: the experience of Haiti and Chile 2010. Nephron Clin Pract 2011;117(3):c184-97. [CrossRef] google scholar
43. Morris JA, Jr., Mucha P, Jr., Ross SE, Moore BF, Hoyt DB, Gentilello L, et al. Acute posttraumatic renal failure: a multicenter perspective. J Trauma 1991;31(12):1584-90. [CrossRef] google scholar
44. Pinsky MR, Brophy P, Padilla J, Paganini E, Pannu N. Fluid and volume monitoring. Int J Artif Organs 2008;31(2):111-26. [CrossRef] google scholar
45. Sever MS, Erek E, Vanholder R, Yurugen B, Kantarci G, Yavuz M, et al. Renal replacement therapies in the aftermath of the catastrophic Marmara earthquake. Kidney Int 2002;62(6):2264-71. [CrossRef] google scholar
46. Schultz CH, Annas GJ. Altering the standard of care in disasters--unnecessary and dangerous. Ann Emerg Med 2012;59(3):191-5. [CrossRef] google scholar
47. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020;382(21):2049-55. [CrossRef] google scholar
48. Sever MS, Lameire N, Vanholder R. Renal disaster relief: from theory to practice. Nephrol Dial Transplant 2009;24(6):1730-5. [CrossRef] google scholar
49. Sever MS, Remuzzi G, Vanholder R. Disaster medicine and response: Optimizing life-saving potential. Am J Disaster Med 2018;13(4):253-64. [CrossRef] google scholar
50. Lameire N, Sever MS, Van Biesen W, Vanholder R. Role of the International and National Renal Organizations in Natural Disasters: Strategies for Renal Rescue. Semin Nephrol 2020;40(4):393-407. [CrossRef] google scholar