Rhabdomyolysis among critically ill combat casualties: associations with acute kidney injury and mortality

Ian J. Stewart, Tarra I. Faulk, Jonathan A. Sosnov, Michael S. Clemens, Joel Elterman, James Ross, Jeffrey T. Howard, Raymond Fang, David Zonies, Kevin K. Chung

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

BACKGROUND: Rhabdomyolysis has been associated with poor outcomes in patients with traumatic injury, especially in the setting of acute kidney injury. However, rhabdomyolysis has not been systematically examined in a large cohort of combat casualties injured in the wars in Iraq and Afghanistan. METHODS: We conducted a retrospective study of casualties injured during combat operations in Iraq and Afghanistan who were initially admitted to the intensive care unit from 1 February 2002 to 1 February 2011. Information on age, sex, abbreviated injury scale score, injury severity score, mechanism of injury, shock index, creatine kinase, and serum creatinine were collected. These variables were examined via multivariate logistic and Cox regression analyses to determine factors independently associated with rhabdomyolysis, acute kidney injury and death. RESULTS: Of 6011 admissions identified, a total of 2109 patients met inclusion criteria and were included for analysis. Rhabdomyolysis, defined by creatine kinase >5,000 U/L, was present in 656 subjects (31.1%). Risk factors for rhabdomyolysis identified on multivariable analysis included injuries to the abdomen and extremities, increased injury severity score, male sex, explosive mechanism of injury and shock index >0.9. After adjustment, patients with rhabdomyolysis had a greater than 2 fold increase in the odds of acute kidney injury. In the analysis for mortality, rhabdomyolysis was significantly associated with death until acute kidney injury was added, at which point it lost statistical significance. CONCLUSIONS: We found that rhabdomyolysis is associated with the development of acute kidney injury in combat casualties. While rhabdomyolysis was strongly associated with mortality on the univariate model and in conjunction with both injury severity score and age, it was not associated with mortality after the inclusion of AKI. This suggests that the effect of rhabdomyolysis on mortality may be mediated by acute kidney injury. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Dec 14 2015

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Rhabdomyolysis
Acute Kidney Injury
Critical Illness
Mortality
Injury Severity Score
Afghanistan
Iraq
Wounds and Injuries
Creatine Kinase
Shock
Abbreviated Injury Scale
Abdomen
Intensive Care Units
Creatinine
Extremities
Retrospective Studies
Logistic Models
Regression Analysis

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Rhabdomyolysis among critically ill combat casualties : associations with acute kidney injury and mortality. / Stewart, Ian J.; Faulk, Tarra I.; Sosnov, Jonathan A.; Clemens, Michael S.; Elterman, Joel; Ross, James; Howard, Jeffrey T.; Fang, Raymond; Zonies, David; Chung, Kevin K.

In: Journal of Trauma and Acute Care Surgery, 14.12.2015.

Research output: Contribution to journalArticle

Stewart, Ian J. ; Faulk, Tarra I. ; Sosnov, Jonathan A. ; Clemens, Michael S. ; Elterman, Joel ; Ross, James ; Howard, Jeffrey T. ; Fang, Raymond ; Zonies, David ; Chung, Kevin K. / Rhabdomyolysis among critically ill combat casualties : associations with acute kidney injury and mortality. In: Journal of Trauma and Acute Care Surgery. 2015.
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abstract = "BACKGROUND: Rhabdomyolysis has been associated with poor outcomes in patients with traumatic injury, especially in the setting of acute kidney injury. However, rhabdomyolysis has not been systematically examined in a large cohort of combat casualties injured in the wars in Iraq and Afghanistan. METHODS: We conducted a retrospective study of casualties injured during combat operations in Iraq and Afghanistan who were initially admitted to the intensive care unit from 1 February 2002 to 1 February 2011. Information on age, sex, abbreviated injury scale score, injury severity score, mechanism of injury, shock index, creatine kinase, and serum creatinine were collected. These variables were examined via multivariate logistic and Cox regression analyses to determine factors independently associated with rhabdomyolysis, acute kidney injury and death. RESULTS: Of 6011 admissions identified, a total of 2109 patients met inclusion criteria and were included for analysis. Rhabdomyolysis, defined by creatine kinase >5,000 U/L, was present in 656 subjects (31.1{\%}). Risk factors for rhabdomyolysis identified on multivariable analysis included injuries to the abdomen and extremities, increased injury severity score, male sex, explosive mechanism of injury and shock index >0.9. After adjustment, patients with rhabdomyolysis had a greater than 2 fold increase in the odds of acute kidney injury. In the analysis for mortality, rhabdomyolysis was significantly associated with death until acute kidney injury was added, at which point it lost statistical significance. CONCLUSIONS: We found that rhabdomyolysis is associated with the development of acute kidney injury in combat casualties. While rhabdomyolysis was strongly associated with mortality on the univariate model and in conjunction with both injury severity score and age, it was not associated with mortality after the inclusion of AKI. This suggests that the effect of rhabdomyolysis on mortality may be mediated by acute kidney injury. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological",
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AU - Clemens, Michael S.

AU - Elterman, Joel

AU - Ross, James

AU - Howard, Jeffrey T.

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AB - BACKGROUND: Rhabdomyolysis has been associated with poor outcomes in patients with traumatic injury, especially in the setting of acute kidney injury. However, rhabdomyolysis has not been systematically examined in a large cohort of combat casualties injured in the wars in Iraq and Afghanistan. METHODS: We conducted a retrospective study of casualties injured during combat operations in Iraq and Afghanistan who were initially admitted to the intensive care unit from 1 February 2002 to 1 February 2011. Information on age, sex, abbreviated injury scale score, injury severity score, mechanism of injury, shock index, creatine kinase, and serum creatinine were collected. These variables were examined via multivariate logistic and Cox regression analyses to determine factors independently associated with rhabdomyolysis, acute kidney injury and death. RESULTS: Of 6011 admissions identified, a total of 2109 patients met inclusion criteria and were included for analysis. Rhabdomyolysis, defined by creatine kinase >5,000 U/L, was present in 656 subjects (31.1%). Risk factors for rhabdomyolysis identified on multivariable analysis included injuries to the abdomen and extremities, increased injury severity score, male sex, explosive mechanism of injury and shock index >0.9. After adjustment, patients with rhabdomyolysis had a greater than 2 fold increase in the odds of acute kidney injury. In the analysis for mortality, rhabdomyolysis was significantly associated with death until acute kidney injury was added, at which point it lost statistical significance. CONCLUSIONS: We found that rhabdomyolysis is associated with the development of acute kidney injury in combat casualties. While rhabdomyolysis was strongly associated with mortality on the univariate model and in conjunction with both injury severity score and age, it was not associated with mortality after the inclusion of AKI. This suggests that the effect of rhabdomyolysis on mortality may be mediated by acute kidney injury. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological

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