剧烈运动致横纹肌溶解并急性肾损伤临床分析

Clinical analysis in patients with rhabdomyolysis and acute kidney injury caused by intense exercise

目的探讨剧烈运动致横纹肌溶解（RM）及相关急性肾损伤（AKI）的临床特点。方法回顾性分析2002年1月至2017年12月22例因剧烈军事训练导致RM合并AKI患者的临床表现、肾功能和肌损伤标志物以及治疗和预后。结果所有22例患者均为青年男性军人，起病前都参加军事跑训练。5 km越野19例（86.4%），5 km徒手2例（9.1%）；发病季节夏季17例（77.3%），其中夏季5 km越野16例（72.7%）。所有患者发病后血肌酐（Scr）、尿素氮（BUN）、尿酸（UA）、肌酸激酶（CK）均明显增高，其中AKI 1期2例（9.1%），2期7例（31.8%），3期13例（59.1%）。相关分析表明CK与AKI分期（r=0.453，P〈0.05）、Scr（r=0.494，P〈0.05）、BUN（r=0.545，P〈0.01）呈正相关，与UA呈负相关（r=- 0.487，P〈0.05）；乳酸脱氢酶（LDH）仅与年龄呈正相关（r=0.533，P〈0.05）；UA与年龄呈正相关（r=0.431，P〈0.05），与血BUN（r=- 0.513，P〈0.05）、K＋（r=- 0.642，P〈0.01）、CK（r=- 0.487，P〈0.05）呈负相关；从发病至就诊时间与血BUN（r=0.907，P〈0.01）、Scr（r=0.690，P〈0.01）呈明显正相关。22例患者经补液等对症支持治疗，其中8例接受连续性静-静脉血液滤过，随访21例（95.5%）肾功能完全恢复，1例（4.5%）遗留慢性肾功能不全。结论剧烈运动易引发RM及相关AKI。早期诊断、综合治疗，并适时行血液净化是成功救治的重要方法，应重视年龄因素在肌肉损伤中的影响作用，注意监测肾功能和肌损伤的标志物及电解质，以期预防RM及相关肾损伤等并发症。

ObjectiveTo investigate the clinical features of patients with rhabdomyolysis and acute kidney injury （AKI） caused by intense exercise.MethodsData on patients with rhabdomyolysis and AKI due to intense military exercise from January 2002 to December 2017 in a single Chinese nephrology center were retrospectively reviewed. Parameters included clinical manifestations, markers of renal function and muscle damage, treatment and prognosis.ResultsTwenty-two male servicemen with AKI caused by rhabdomyolysis were included. They took part in the military running training before onset. 95.5%（21/22） took part in 5-kilometer race, of which cross-country was 86.4% （19 cases） and bare-handed was 9.1% （2 cases）. Most cases occurred in summer, in which 72.7% （16 cases） took part in 5-kilometer cross-country race. The levels of serum creatinine （Scr）, blood urea nitrogen （BUN）, uric acid （UA） and creatine kinase （CK） significantly increased in patients, with 9.1% （2 cases） reaching AKI stage 1, 31.8% （7 cases） reaching AKI stage 2, and 59.1% （13 cases） reaching AKI stage 3, respectively. Serum CK levels were positively correlated with AKI stage （r=0.453, P〈0.05）, Scr （r=0.494, P〈0.05） and BUN （r=0.545, P〈0.01）, while negatively correlated with UA （r=- 0.487, P〈0.05）. Serum LDH levels were positively correlated only with age （r=0.533, P〈0.05）. Serum UA presented inverse correlations with BUN （r=- 0.513, P〈0.05）, K＋ （r=- 0.642, P〈0.01） and CK （r=- 0.487, P〈0.05）, and positive correlation with age （r=0.431, P〈0.05）. In particular, duration from onset of disease had a stronger positive association with BUN （r=0.907, P〈0.01） and Scr （r=0.690, P〈0.01）. Of these patients with AKI, 21 cases（95.5%） reached complete recovery of kidney function and 1 case （4.5%） changed to chronic renal failure within 3 months after comprehensive treatments, including 8 cases（36.4%） who received appropriate continuous venovenous hemofiltration.ConclusionsIntense exercise in summer is likely to cause rhabdomyolysis and AKI. Early diagnosis and comprehensive treatment including appropriate blood purification are crucial for a successful treatment. Our findings also emphasize the importance of age on muscle injury and the monitoring of electrolysts, markers of muscle damage and renal function for prevention of rhabdomyolysis and its related complications.