Letter to the Editor
Rhabdomyolysis and acute kidney injury associated with Clostridium difficile infection, case report
Rabdomiólisis y daño renal agudo asociado a infección por Clostridium difficile, reporte de caso
Guillermo Navarro-Blackaller
, Jonathan Samuel Chávez-Iñiguez, Pablo Maggiani-Aguilera, Gema Lizeth Gómez-Hernández, Elsa Edith Carreón-Bautista, Rodolfo Alejandro Moreno-Alvarado, Guillermo Garcia-Garcia
Corresponding author
Servicio de Nefrología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
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Carmen Jiménez Herrero, Vladimir Petkov Stoyanov, M. José Gutiérrez Sánchez, Juan A. Martín Navarro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M. Carmen" "apellidos" => "Jiménez Herrero" ] 1 => array:2 [ "nombre" => "Vladimir" "apellidos" => "Petkov Stoyanov" ] 2 => array:2 [ "nombre" => "M. José" "apellidos" => "Gutiérrez Sánchez" ] 3 => array:2 [ "nombre" => "Juan A." "apellidos" => "Martín Navarro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699518301486" "doi" => "10.1016/j.nefro.2018.08.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699518301486?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251419300550?idApp=UINPBA000064" "url" => "/20132514/0000003900000002/v1_201904270637/S2013251419300550/v1_201904270637/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Rhabdomyolysis and acute kidney injury associated with <span class="elsevierStyleItalic">Clostridium difficile</span> infection, case report" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "208" "paginaFinal" => "209" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Guillermo Navarro-Blackaller, Jonathan Samuel Chávez-Iñiguez, Pablo Maggiani-Aguilera, Gema Lizeth Gómez-Hernández, Elsa Edith Carreón-Bautista, Rodolfo Alejandro Moreno-Alvarado, Guillermo Garcia-Garcia" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Guillermo" "apellidos" => "Navarro-Blackaller" "email" => array:1 [ 0 => "greenavarroblackalle@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jonathan Samuel" "apellidos" => "Chávez-Iñiguez" ] 2 => array:2 [ "nombre" => "Pablo" "apellidos" => "Maggiani-Aguilera" ] 3 => array:2 [ "nombre" => "Gema Lizeth" "apellidos" => "Gómez-Hernández" ] 4 => array:2 [ "nombre" => "Elsa Edith" "apellidos" => "Carreón-Bautista" ] 5 => array:2 [ "nombre" => "Rodolfo Alejandro" "apellidos" => "Moreno-Alvarado" ] 6 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Garcia-Garcia" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico" "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" => "Rabdomiólisis y daño renal agudo asociado a infección por <span class="elsevierStyleItalic">Clostridium difficile</span>, reporte de caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rhabdomyolysis (RBD) is a syndrome characterised by skeletal muscle necrosis and the release into the bloodstream of the intracellular constituents, which can lead to severe acute kidney injury (AKI). The causes of the RBD may be divided into traumatic and non-traumatic or metabolic, which in turn can be divided into several hereditary causes (disorders of gluconeogenesis, mitochondrial myopathies) and acquired, such as drugs, infections, toxins, ischaemia or vascular occlusion processes, exertional myolysis (strenuous exercise, seizures), electrolyte disorders (sodium disorders, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypocalcaemia), endocrine disorders (diabetic ketoacidosis, hyperosmolar state, myxoedema, hyperaldosteronism) and inflammatory autoimmune myopathies.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–6</span></a> There are few published studies on RBD and AKI associated with <span class="elsevierStyleItalic">Clostridium difficile</span> (CD).</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 60-year-old man with chronic liver disease. He had an eight-day history of diarrhoea. The results of the tests performed are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> according to the timeline. The patient's inflammatory diarrhoea was found to have AB toxins positive for CD, for which he received metronidazole and later oral vancomycin; he then developed acute kidney injury (AKI), elevated creatine phosphokinase (CPK) and elevated liver enzymes. Urinalysis showed myoglobinuria. Hydration was given with crystalloids, and there was an improvement in AKI and muscle pain and normalisation of CPK. Seven days later, the patient was discharged from hospital asymptomatic.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">RBD may cause AKI in up to 33% of cases. The risk is usually low when CPK levels are below 15,000–20,000<span class="elsevierStyleHsp" style=""></span>IU/l, but it can occur with values starting from 5000<span class="elsevierStyleHsp" style=""></span>IU/l. It has been proposed by consensus that to induce AKI the CPK should be over 100 times its highest normal value, accompanied by a clinical syndrome.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are three pathogenic mechanisms involved in the development of RBD-related AKI: vasoconstriction, tubular obstruction and direct oxidative damage of myoglobin in renal tubuler cells.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Tubular obstruction and oxidative injury is due to the precipitation of the Tamm-Horsfall protein with myoglobin; under physiological conditions, myoglobin is reabsorbed by the renal tubule cells, but when the presence of this pigment exceeds the reabsorptive capacity, it precipitates in the tubules as pigmentary cylinders,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> forming hyaline cylinders and causing endothelial dysfunction and tissue damage due to multiple cytokines, TNF-α, thromboxane A2 and endothelin. This all activates the sympathetic nervous system, the renin–angiotensin–aldosterone system and vasopressin release, which together reduce urine output.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Last of all, the haem component of myoglobin causes oxidative damage in the tubules due to the production of active iron-induced oxygen radicals.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical expression varies from asymptomatic forms to electrolyte imbalance, respiratory distress syndrome, AKI, disseminated intravascular coagulation and multiple organ failure.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The most common clinical presentation is muscle pain (84%), dark urine (80%), weakness (73%) and muscle swelling (8.1%).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Infections are an uncommon cause of RBD, representing approximately 5% of cases, and 33–50% of them go on to develop AKI.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> There are few cases of RBD caused by CD reported in the literature. The Food and Drug Administration (FDA) has reported nine cases to date.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Muralikrishna et al. reported the first case of RBD caused by CD, in a 57-year-old male with a history of irritable bowel syndrome with diarrhoea; CD was confirmed by ELISA of stool sample with the test positive for A and B toxins, with elevation of CPK<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>25,300<span class="elsevierStyleHsp" style=""></span>IU/l and elevation of urinary myoglobin. The patient was treated with intravenous fluids, metronidazole and oral vancomycin. His symptoms resolved completely and he was discharged one week after admission.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The FDA cases were males aged 50–59. In terms of comorbidities, eight of the nine patients were post-transplant, with dyslipidaemia and metabolic acidosis, and the other patient had rheumatoid arthritis. All the cases were taking prednisone and six of them (66.77%) were also taking sodium bicarbonate, simvastatin, dalteparin and darbepoetin. Clinical presentation was with AKI in eight patients (88.89%), myopathy and hyperkalaemia in five patients (55.56%) and diarrhoea in only 33%.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The combination of drugs with risk of RBD, immunosuppression by steroids, chronic kidney disease or chronic liver disease in our patient are known risk factors for CD, but little is known about the risk of developing RBD. The mechanism behind RBD caused by CD is uncertain, but the direct cytotoxic effect of CD toxins remains the most likely possibility.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The description of additional cases with RBD and AKI caused by CD would aid our understanding of the pathophysiological mechanisms of this serious complication and help standardise management.</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: Navarro-Blackaller G, Chávez-Iñiguez JS, Maggiani-Aguilera P, Gómez-Hernández GL, Carreón-Bautista EE, Moreno-Alvarado RA, et al. Rabdomiólisis y daño renal agudo asociado a infección por <span class="elsevierStyleItalic">Clostridium difficile</span>, reporte de caso. Nefrologia. 2019;39:208–209.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests are shown on admission and during hospitalisation until returning to normal.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laboratory \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">05/03/2018 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">07/03/2018 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">09/03/2018 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">10/03/2018 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">11/03/2018 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Platelets (thousands/μg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leucocytes (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glucose (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urea (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">114 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">146 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">174 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">112 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatine phosphokinase (U/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2525 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32,437 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29,130 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">924 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">126 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Albumin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sodium (mmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">131 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">136 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chlorine (mmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phosphorus (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Potassium (mmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alanine aminotransferase (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">182 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">444 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aspartate aminotransferase (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">834 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1814 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gamma-glutamyl transferase (IU/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2018707.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests and patient follow-up.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ischemic rhabdomyolysis and acute renal failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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| 2024 June | 59 | 47 | 106 |
| 2024 May | 42 | 40 | 82 |
| 2024 April | 42 | 27 | 69 |
| 2024 March | 45 | 21 | 66 |
| 2024 February | 28 | 43 | 71 |
| 2024 January | 42 | 26 | 68 |
| 2023 December | 28 | 19 | 47 |
| 2023 November | 34 | 37 | 71 |
| 2023 October | 66 | 35 | 101 |
| 2023 September | 62 | 28 | 90 |
| 2023 August | 39 | 35 | 74 |
| 2023 July | 42 | 30 | 72 |
| 2023 June | 25 | 33 | 58 |
| 2023 May | 40 | 40 | 80 |
| 2023 April | 40 | 19 | 59 |
| 2023 March | 42 | 25 | 67 |
| 2023 February | 82 | 14 | 96 |
| 2023 January | 60 | 33 | 93 |
| 2022 December | 45 | 21 | 66 |
| 2022 November | 71 | 39 | 110 |
| 2022 October | 83 | 43 | 126 |
| 2022 September | 62 | 44 | 106 |
| 2022 August | 55 | 56 | 111 |
| 2022 July | 53 | 45 | 98 |
| 2022 June | 52 | 49 | 101 |
| 2022 May | 66 | 40 | 106 |
| 2022 April | 61 | 55 | 116 |
| 2022 March | 69 | 68 | 137 |
| 2022 February | 75 | 54 | 129 |
| 2022 January | 70 | 31 | 101 |
| 2021 December | 51 | 47 | 98 |
| 2021 November | 77 | 46 | 123 |
| 2021 October | 59 | 68 | 127 |
| 2021 September | 50 | 45 | 95 |
| 2021 August | 44 | 52 | 96 |
| 2021 July | 42 | 42 | 84 |
| 2021 June | 43 | 38 | 81 |
| 2021 May | 80 | 47 | 127 |
| 2021 April | 111 | 76 | 187 |
| 2021 March | 68 | 46 | 114 |
| 2021 February | 67 | 43 | 110 |
| 2021 January | 38 | 29 | 67 |
| 2020 December | 42 | 18 | 60 |
| 2020 November | 33 | 30 | 63 |
| 2020 October | 25 | 28 | 53 |
| 2020 September | 46 | 16 | 62 |
| 2020 August | 28 | 22 | 50 |
| 2020 July | 32 | 25 | 57 |
| 2020 June | 36 | 41 | 77 |
| 2020 May | 45 | 31 | 76 |
| 2020 April | 56 | 27 | 83 |
| 2020 March | 41 | 19 | 60 |
| 2020 February | 39 | 37 | 76 |
| 2020 January | 89 | 46 | 135 |
| 2019 December | 43 | 31 | 74 |
| 2019 November | 58 | 30 | 88 |
| 2019 October | 36 | 10 | 46 |
| 2019 September | 50 | 21 | 71 |
| 2019 August | 32 | 15 | 47 |
| 2019 July | 59 | 35 | 94 |
| 2019 June | 44 | 33 | 77 |
| 2019 May | 45 | 31 | 76 |
| 2019 April | 82 | 62 | 144 |
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