Letter to the Editor
Acute kidney injury secondary to rhabdomyolysis in a nonagenarian patient taking statins. Lessons to be considered
Fracaso renal agudo secundario a rabdomiólisis por estatinas en una paciente nonagenaria. Lecciones a tener en cuenta
Jose Maria Peña-Porta
, Alba Martinez-Burillo, Oscar Urbano-Gonzalo, Rafael Alvarez-Lipe
Corresponding author
Servicio de Nefrología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Lessons to be considered" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "181" "paginaFinal" => "182" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jose Maria Peña-Porta, Alba Martinez-Burillo, Oscar Urbano-Gonzalo, Rafael Alvarez-Lipe" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Jose Maria" "apellidos" => "Peña-Porta" "email" => array:1 [ 0 => "jpenaporta@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alba" "apellidos" => "Martinez-Burillo" ] 2 => array:2 [ "nombre" => "Oscar" "apellidos" => "Urbano-Gonzalo" ] 3 => array:2 [ "nombre" => "Rafael" "apellidos" => "Alvarez-Lipe" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso renal agudo secundario a rabdomiólisis por estatinas en una paciente nonagenaria. Lecciones a tener en cuenta" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Elderly patients with chronic kidney disease (CKD) are more prone to develop episodes of acute kidney injury (AKI), frequently resulting from drug dosage non adjusted for glomerular filtration rate (GFR) or by drug-to-drug interactions due to CKD. We present a case of AKI secondary to rhabdomyolysis in a nonagenarian patient taking statins as well as other potentially nephrotoxic drugs. A comment on practical lessons to be learned has also been included.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 91-year-old patient with a history of hypertension (HTN) and hypercholesterolaemia diagnosed at the age of 85 on treatment with atorvastatin 10<span class="elsevierStyleHsp" style=""></span>mg. Two years later the patient was switched to rosuvastatin 20<span class="elsevierStyleHsp" style=""></span>mg because of poor control of cholesterol levels. Treatment with this drug was continued with normalization of cholesterol levels. The rest of treatment included telmisartan 80<span class="elsevierStyleHsp" style=""></span>mg, hydrochlorothiazide 25<span class="elsevierStyleHsp" style=""></span>mg, esomeprazole 40<span class="elsevierStyleHsp" style=""></span>mg and ibuprofen 600<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h for the management of arthralgia. The serum creatinine levels was 1.55<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient presented at the emergency room with a history of 72<span class="elsevierStyleHsp" style=""></span>h of sudden right flank pain without irradiation, accompanied by oliguria, and no fever. She also complained of muscle weakness in lower extremities.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination showed no remarkable findings except for decreased osteotendinous reflexes in lower extremities.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lab results upon admission were: haemoglobin 13.3<span class="elsevierStyleHsp" style=""></span>g/dl, glucose 99<span class="elsevierStyleHsp" style=""></span>mg/dl, creatinine 4.47<span class="elsevierStyleHsp" style=""></span>mg/dl, urea 1.24<span class="elsevierStyleHsp" style=""></span>g/l, albumin 3.28<span class="elsevierStyleHsp" style=""></span>g/dl, AST 360<span class="elsevierStyleHsp" style=""></span>U/l, ALT 165<span class="elsevierStyleHsp" style=""></span>U/l, GGT 11<span class="elsevierStyleHsp" style=""></span>U/l, alkaline phosphatase 93<span class="elsevierStyleHsp" style=""></span>U/l, amylase 58<span class="elsevierStyleHsp" style=""></span>U/l, total cholesterol 117<span class="elsevierStyleHsp" style=""></span>mg/dl, uric acid 6.3<span class="elsevierStyleHsp" style=""></span>mg/dl, sodium 138<span class="elsevierStyleHsp" style=""></span>mEq/l, potassium 2.93<span class="elsevierStyleHsp" style=""></span>mEq/l, chloride 90.7<span class="elsevierStyleHsp" style=""></span>mEq/l, pH 7.45, pCO<span class="elsevierStyleInf">2</span> 38<span class="elsevierStyleHsp" style=""></span>mmHg, CO<span class="elsevierStyleInf">3</span>H 26.1<span class="elsevierStyleHsp" style=""></span>mmol/l; proteinuria: 0.6<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h, and CPK 9.612<span class="elsevierStyleHsp" style=""></span>μ/l.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Abdominal ultrasound showed kidneys normal in size and structure, without evidence of pelvicalyceal ectasia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fluid therapy was initiated, followed by progressive recovery of renal function together with complete normalization of CPK and transaminases levels. Creatinine was 1.9<span class="elsevierStyleHsp" style=""></span>mg/dl at discharge and 1.44<span class="elsevierStyleHsp" style=""></span>mg/dl 2 months later according to outpatient readings.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our patient had an episode of rhabdomyolysis-related AKI, which was likely associated to the use of rosuvastatin since no other cause of rabdomyilysis was detected.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Of note, the patient, who had CKD stage 4 according to KDIGO<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> with a baseline CKD-EPI GFR of 29.06<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>. was receiving excessive dose of rosuvastatin.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The present case illustrate the importance of outpatient measurements of GFR in elderly patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> According to its core data sheet, the use of rosuvastatin is not recommended in patients with a GFR <30<span class="elsevierStyleHsp" style=""></span>ml/min, with a starting dose of 5<span class="elsevierStyleHsp" style=""></span>mg/day indicated for elderly patients. The stage of CKD may have been missed in primary care if the GFR was not measured using equations.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The undeniable usefulness of statins for primary prevention among patients aged 85 and over can also be discussed.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The special feature of this report lies in the fact that our patient developed rhabdomyolysis following long-term treatment with statins (5 years) an almost unparalleled case in the literature, suggesting that the complication may arise at any time. Muscle necrosis has been described following treatment with both drugs.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> Between 15 and 33% of patients develop AKI.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Up to 37% of them require haemodialysis. Mortality is 5%, although it rises to 25% when complicated by AKI.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The mechanism of muscle toxicity is not fully understood. Statins may interfere in the synthesis of the Q10 coenzyme (CoQ10 or ubiquinone) involved in energy production of muscle cells.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Muscular symptoms usually start weeks or months after the initiation of treatment, but just as in our patient, it may occur at any time. In a series including 44 patients, mean treatment duration before symptoms was 6.3 months (range: 0.25–48). Symptoms resolved following drug withdrawal after a mean of 2.3 months (range: 0.25–14).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Also important is the fact that the patient was taking the following drugs: a non-steroid anti-inflammatory drug, an angiotensin receptor antagonist, and a diuretic. This combination is sometimes referred to as a “Triple whammy” and has been associated with a higher incidence of AKI.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In our patient, other drugs may have led to decreased GFR and the development of muscle necrosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary, our case highlights the need for a thorough assessment of the risk-benefit profile when prescribing drugs to elderly patients with CKD, which should be staged based on the measurement of GFR. Statin-associated rhabdomyolysis may occur at any time of the disease course, while concomitant use with certain drugs may increase toxicity.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Peña-Porta JM, Martinez-Burillo A, Urbano-Gonzalo O, Alvarez-Lipe R. Fracaso renal agudo secundario a rabdomiólisis por estatinas en una paciente nonagenaria. Lecciones a tener en cuenta. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 55 | 48 | 103 |
| 2024 September | 63 | 29 | 92 |
| 2024 August | 80 | 67 | 147 |
| 2024 July | 47 | 35 | 82 |
| 2024 June | 61 | 42 | 103 |
| 2024 May | 61 | 35 | 96 |
| 2024 April | 53 | 30 | 83 |
| 2024 March | 42 | 20 | 62 |
| 2024 February | 39 | 36 | 75 |
| 2024 January | 33 | 26 | 59 |
| 2023 December | 25 | 18 | 43 |
| 2023 November | 32 | 28 | 60 |
| 2023 October | 37 | 31 | 68 |
| 2023 September | 24 | 25 | 49 |
| 2023 August | 37 | 18 | 55 |
| 2023 July | 40 | 22 | 62 |
| 2023 June | 42 | 16 | 58 |
| 2023 May | 46 | 38 | 84 |
| 2023 April | 31 | 18 | 49 |
| 2023 March | 42 | 21 | 63 |
| 2023 February | 20 | 17 | 37 |
| 2023 January | 37 | 21 | 58 |
| 2022 December | 43 | 31 | 74 |
| 2022 November | 56 | 22 | 78 |
| 2022 October | 42 | 45 | 87 |
| 2022 September | 41 | 37 | 78 |
| 2022 August | 40 | 50 | 90 |
| 2022 July | 35 | 44 | 79 |
| 2022 June | 37 | 19 | 56 |
| 2022 May | 35 | 39 | 74 |
| 2022 April | 31 | 36 | 67 |
| 2022 March | 45 | 42 | 87 |
| 2022 February | 52 | 35 | 87 |
| 2022 January | 40 | 30 | 70 |
| 2021 December | 42 | 33 | 75 |
| 2021 November | 38 | 37 | 75 |
| 2021 October | 42 | 45 | 87 |
| 2021 September | 34 | 34 | 68 |
| 2021 August | 30 | 36 | 66 |
| 2021 July | 37 | 27 | 64 |
| 2021 June | 31 | 24 | 55 |
| 2021 May | 26 | 29 | 55 |
| 2021 April | 127 | 40 | 167 |
| 2021 March | 67 | 34 | 101 |
| 2021 February | 48 | 34 | 82 |
| 2021 January | 47 | 19 | 66 |
| 2020 December | 31 | 16 | 47 |
| 2020 November | 43 | 18 | 61 |
| 2020 October | 43 | 20 | 63 |
| 2020 September | 38 | 14 | 52 |
| 2020 August | 52 | 17 | 69 |
| 2020 July | 52 | 14 | 66 |
| 2020 June | 59 | 9 | 68 |
| 2020 May | 61 | 16 | 77 |
| 2020 April | 38 | 20 | 58 |
| 2020 March | 40 | 17 | 57 |
| 2020 February | 45 | 19 | 64 |
| 2020 January | 54 | 17 | 71 |
| 2019 December | 66 | 21 | 87 |
| 2019 November | 59 | 18 | 77 |
| 2019 October | 41 | 12 | 53 |
| 2019 September | 30 | 14 | 44 |
| 2019 August | 32 | 12 | 44 |
| 2019 July | 48 | 26 | 74 |
| 2019 June | 38 | 20 | 58 |
| 2019 May | 43 | 19 | 62 |
| 2019 April | 48 | 33 | 81 |
| 2019 March | 45 | 20 | 65 |
| 2019 February | 29 | 14 | 43 |
| 2019 January | 52 | 25 | 77 |
| 2018 December | 149 | 50 | 199 |
| 2018 November | 193 | 20 | 213 |
| 2018 October | 186 | 12 | 198 |
| 2018 September | 149 | 16 | 165 |
| 2018 August | 72 | 19 | 91 |
| 2018 July | 62 | 10 | 72 |
| 2018 June | 82 | 15 | 97 |
| 2018 May | 124 | 16 | 140 |
| 2018 April | 107 | 5 | 112 |
| 2018 March | 78 | 13 | 91 |
| 2018 February | 82 | 7 | 89 |
| 2018 January | 91 | 7 | 98 |
| 2017 December | 62 | 8 | 70 |
| 2017 November | 58 | 11 | 69 |
| 2017 October | 43 | 9 | 52 |
| 2017 September | 45 | 11 | 56 |
| 2017 August | 39 | 11 | 50 |
| 2017 July | 46 | 17 | 63 |
| 2017 June | 54 | 10 | 64 |
| 2017 May | 60 | 17 | 77 |
| 2017 April | 49 | 12 | 61 |
| 2017 March | 28 | 15 | 43 |
| 2017 February | 29 | 7 | 36 |
| 2017 January | 29 | 8 | 37 |
| 2016 December | 49 | 14 | 63 |
| 2016 November | 66 | 18 | 84 |
| 2016 October | 48 | 19 | 67 |
| 2016 September | 103 | 1 | 104 |
| 2016 August | 104 | 3 | 107 |
| 2016 July | 166 | 5 | 171 |
| 2016 June | 114 | 0 | 114 |
| 2016 May | 154 | 0 | 154 |
| 2016 April | 110 | 0 | 110 |
| 2016 March | 75 | 0 | 75 |
| 2016 February | 12 | 0 | 12 |
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