Incidence and outcome of rhabdomyolysis after type A Aortic Dissection surgery -a retrospective analysis
Praveen C Sivadasan1 * Email: drpraveencs@gmail.com Amr S Omar1.2,3Email: a_s_omar@yahoo.com Cornelia S Carr1Email: ccarr@hamad.qa Abdul Rasheed A Pattath 1,3Email: drrashmanson@gmail.com Samy Hanoura1,3,4Email: sehanoura73@yahoo.com Suraj Sudarsanan1Email: drsurajsudarsan@gmail.com Hany Ragab1Email: Hanyragab73@gmail.com Hatem Sarhan1,5Email: HSarhan2@hamad.qa Arunabha Karmakar1,5Email: arunabha.karmakar@gmail.com
Rajvir Singh 5
Email: rsingh@hamad.qa
  1. Department of Cardiothoracic Surgery/Cardiac Anaesthesia & ICU Section, Heart Hospital, Hamad Medical Corporation, Doha, (PO Box: 3050), Qatar
  2. Department of Critical Care Medicine, Beni Suef University, Egypt
  3. Weill Cornell Medical College-Qatar, Doha, Qatar
  4. Department of Anesthesia, Al-Azhar University, Cairo, Egypt
  5. Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
  6. Department of Medical Research, Hamad Medical Corporation, Doha, Qatar
* Corresponding author. Department of Cardiothoracic Surgery/Cardiac Anaesthesia & ICU Section, Heart Hospital, Hamad Medical Corporation, Doha, (PO: 3050), Qatar Email: drpraveencs@gmail.comIncidence and outcome of rhabdomyolysis after type A aortic dissection surgery. A single center retrospective analysisIntroduction
Despite ongoing research, the etiology of acute kidney injury (AKI) remains incompletely understood; especially after aortic dissection surgeries. The association of rhabdomyolysis (RML) and acute kidney injury (AKI) with cardiac surgery has been evaluated and reported by us in a recently concluded study1, but there is a lack of robust data regarding the same in aortic dissection surgeries specifically.
Rhabdomyolysis is a syndrome characterized by breakdown of skeletal muscles and release of toxic intracellular contents into the systemic circulation causing damage to renal tubules. RML may be caused by a myriad of etiologies, predominantly by direct trauma to muscles as seen in crush injuries, burns or prolonged muscle compression. It could also be associated with congenital disorders of metabolism, certain drugs like anesthetic agents, neuroleptic agents and statins, infections and sustained muscle contraction (seizures and prolonged exercise for example)2. The illness might vary in severity from asymptomatic elevations in markers of muscle injury (namely Creatinine Kinase (CK) and Myoglobin); to severe cases associated with extreme enzyme elevation and renal shut down culminating in dialysis3. Postoperative Rhabdomyolysis is being increasingly recognized as a cause of renal failure. RML is a well-known complication after bariatric, Urologic and orthopedic surgery4. One retrospective review which analyzed myoglobin as a marker of myocardial injury post-cardiac surgery reported myoglobin to be superior to creatine kinase (CK) for prediction of mortality and need for renal replacement therapy5. The literature linking RML to cardiac surgery was largely confined to isolated case reports6 until our study1 was published. The aforementioned study in our center, in which we noticed an unusually high incidence of RML among the patients undergoing type A aortic dissection repair laid the foundation for this broader retrospective analysis specifically looking for a link between RML and aortic surgeries.
Acute kidney injury (AKI) complicates recovery from cardiac surgery in up to 30 % of patients and places patients at a 5-fold increased risk of death during hospitalization. Etiology is often multifactorial and preventive strategies are limited. AKI that requires renal replacement therapy occurs in 2–5 % of patients following cardiac surgery and is associated with 50 % mortality7.
Aortic surgeries are specifically associated with a higher incidence of renal complications than other types of cardiac surgery (with a reported incidence of AKI ranging from 18% to 55%)8. A significant number of patients with ascending aortic dissection (AAD) have chronic renal impairment on presentation9. Renal failure and dialysis after aortic dissection surgery is an independent predictor of mortality as per the International Registry of Acute Aortic Dissection. Perioperative predictors for postoperative AKI and renal replacement therapy according to various studies were estimated preoperative glomerular filtration rate, coronary ischemic time, renal artery involvement in dissection, total arch replacement, preoperative oliguria, longer cardiopulmonary bypass and hypothermic circulatory arrest times, high body mass index, elevated C reactive protein, perioperative sepsis and postoperative bleeding requiring a surgical revision10-14. Till date, there are no published studies linking rhabdomyolysis with aortic dissection except for a single case report15. Myoglobin has reportedly been linked to renal morbidity and mortality after thoracic and thoraco-abdominal aortic surgeries16