Rhabdomyolysis induced acute renal failure secondary to statins
A 65-year-old lady was suffering from type 2 diabetes for the past 30 years, hypertension for the past 20 years, and coronary heart disease for the past 10 years. She was diagnosed chronic kidney disease about 6 months ago. Her serum creatinine was stable at 2.0 mg/dL. The medications included clopidogrel 75 mg/day, amlodipine 10 mg/day, frusemide 40 mg bds, and insulin. A week before presenting to us, a cardiologist had added atorvastatin 10 mg/day to her prescription. She presented to us with complaints of severe generalized myalgia, difficulty in assuming upright posture from sitting position, and difficulty in walking of 1 week duration. She also complained of swelling of feet, face, nausea, loss of appetite and noticed decreased urine output, and reddish discoloration to urine for the last 3 days. There was no fever, history of trauma, viral exanthem, severe exercise, seizure, uncontrolled blood glucose, and use of herbal medication preceding the illness. On examination, she was well-built and well-nourished, and had pedal edema and facial puffiness. There was no icterus, no clubbing, and no lymphadenopathy. She was afebrile with pulse rate of 60 beats per min and blood pressure of 160/90 mm Hg. Neurological examination showed 2/5 power in all four limbs, absent deep tendon reflexes, and muscle tenderness with no sensory involvement. Examination of cardiovascular, respiratory, and gastrointestinal systems was unremarkable. The investigations are presented in .\nUrinalysis showed glucose 2+, ketone bodies negative, blood positive, red blood cells nil, and white blood cells 1-2/hpf. Her hemoglobin was 11.4 g/dL, total leukocyte count 18, 300 per mm3, platelet count 5.0 lakh per mm3, ESR 20 mm after 1 h, electrocardiogram showed tall peaked and widened T waves with proximal limb steeper than distal limb, and the chest radiograph was normal. Ultrasound abdomen showed right kidney 9.3 × 3.7 cm and left kidney 9.2 × 3.2 cm. The urine and blood cultures were sterile, HIV, HBsAg, anti-HCV antibodies, anti-HAV IgM, and anti-HEV IgM were negative.\nPatient was initiated on hemodialysis. Myalagia, reddish discoloration to urine, deterioration of renal function, elevated SGOT, creatinine kinase, and increased urine myoglobin led to the diagnosis of rhabdomyolysis. Atorvastatin was stopped. Levothyroxine replacement was initiated at a dose of 50 μg/day, increased after 15 days to 100 μg/day. The following three risk factors for the onset of rhabdomyolysis were identified: Use of statin, undiagnosed hypothyroidism, and co-administration of amlodipine and clopidogrel. Amlodipine and clopidogrel were also withheld. Frusemide was stopped as she had hypokalemia before the onset of illness which was again a risk factor for rhabdomyolysis. After seven sessions of hemodialysis the urine output improved and serum creatinine stabilized at 3.2 mg/dL. Creatine kinase and SGOT levels returned to normal. She regained power in all limbs. Deep tendon reflexes appeared again.