Characteristics and Thirty‐day Outcomes of Emergency Department Patients With Elevated Creatine Kinase

Abstract

Objectives: Rhabdomyolysis, as defined by an elevation in creatine kinase (CK), may lead to hemodialysis and death in emergency department (ED) patients, but the patient characteristics, associated conditions, and 30-day outcomes of patients with CK values over 1,000 U/L have not been described. Methods:All consecutive ED patients with serum CK values over 1,000 U/L between January 1, 2006, and December 31, 2008, were retrospectively identified from two urban hospitals. Patient characteristics, ED treatment, and ED discharge diagnoses were determined by medical record review. Provincial databases were linked to identify patients who died or were treated with hemodialysis within 30 days. The primary outcome was the combined occurrence of death or need for hemodialysis within 30 days. Secondary outcomes included the incidence of acute kidney injury (AKI) and the proportion of patients with initial estimated glomerular filtration rates (eGFR) > 60 mL/min/1.73 m 2 who died or required hemodialysis.Results: Four-hundred patients were identified, the median age was 50 years (interquartile range [IQR] = 35 to 69 years), and 77% were male, with 35% of patients discharged home from the ED. The most common ED discharge diagnoses were related to recreational drug use, infections, and traumatic or musculoskeletal complaints. Within 30 days, 32 (8.0%, 95% confidence interval [CI] = 5.3% to 11%) experienced primary outcomes, with 18 (4.5%, 95% CI = 2.55% to 6.5%) requiring hemodialysis and 21 deaths (5.3%, 95% CI = 3.1% to 7.4%). AKI occurred in 151 patients (38%, 95% CI = 33% to 43%). Of the 257 patients (64%) with initial eGFRs > 60 mL/min/1.73 m 2 , none required hemodialysis. Conclusions:In ED patients with initial CK > 1,000 U/L, the incidence of death or hemodialysis was 8% within 30 days. Patients with initial eGFRs > 60 mL/min/1.73 m 2 appear to be at a low risk of these outcomes from rhabdomyolysis.ACADEMIC EMERGENCY MEDICINE 2014;21:631-636

Risk factors for acute kidney injury among patients with rhabdomyolysis

“…Compared with other causes, patients with RM resulting from sepsis, bee sting and acute alcoholism were observed more frequently in the AKI group. In our study, the morbidity rate of AKI was 61.4%, which is almost in accord with previous reports [7][8][9][10], although this number varies between different studies.…”

“…Intracellular components released into the circulation cause capillary damage, which leads to leakage and edema, secondary hypovolemia and decreased renal blood flow, and ultimately reduce renal function [2,6]. The incidence of AKI is reported to be between 37.8 and 79.5% in patients with RM [7][8][9][10], and is independently associated with a 19.2-59% increase in mortality [9,11,12]. The occurrence of AKI is associated with a worse outcome in patients with RM, which increases medical burden; thus, the prevention and early diagnosis of AKI are critical to improving patient prognosis.…”

Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice

“…Dark urine reported in 5.4 % of patients Talving et al 2013 [ 28 ] RS Pediatric trauma patients NA Trauma NA RM = 521 AKI occurred in 70 patients. The authors concluded that a CK level ≥3000 was an independent risk factor for developing AKI Grunau et al 2014 [ 29 ] RS Patients in the ED CK levels >1000 U/L Illicit drug use, infections, trauma NA RM = 400 AKI developed in 151 patients; 18 patients required hemodialysis van Staa et al 2014 [ 30 ] RS 641,703 statin users CK levels 10× the upper limit of normal Statin drug use Drug–drug interaction Reported with RM = 59 CK >10× = 182 The incidence of RM in this cohort of statin users was very low Pariser et al 2015 [ 31 ] RS 1,016,074 patients with a major urologic surgery NA NA Diabetes, chronic kidney disease, obesity, bleeding, age and male sex RM = 870 Surgeries associated with RM were nephrectomy (radical or partial) and radical cystectomy Abbreviations: AKI acute kidney injury, BMI body mass index, CK creatine kinase, ED emergency department, ICU intensive care unit, NA not available, POS prospective observational study, RM rhabdomyolysis, RS retrospective study …”

Causes of creatine kinase levels greater than 1000 IU/L in patients referred to rheumatology

“…This database was searched for records with a CK concentration greater than 1,000 IU/L and the word “rheumatology” in a clinical note, problem list, discharge summary, clinical communication, or letter. The cut-off of 1,000 IU/L was chosen in order to remain consistent with the existing literature reviewing the causes of severely elevated CK concentrations in a general adult population [2, 3], and also because in our experience a CK concentration greater than 1,000 IU/L is often concerning enough to other providers to prompt a rheumatology referral, even in the absence of other clinical features of an IIM.…”

“…Musculoskeletal trauma, myocardial injury, infections, and drug-induced myositis are the most common causes encountered in general clinical practice [2, 3]. However, there are many other endocrinologic, neuropsychiatric, neuromuscular, metabolic, and rheumatologic etiologies that must be considered when CK concentrations are severely elevated [4-9].…”