Full text of DOI:10.1177/107424840000500105

After
Failure
Acute Renal
Cardiopulmonary
Drugs
Bypass:
of
With
Possible Association
the Fibrate
A
Group
Brendan P.
KamelM.
MRCP,*
Madden,
Sharobeem,
MD,
Rolfe,
MRCP,*
F
R
ag
C
g
P
er
,
;
M.
Russell
F
R
ag
C
g
S
er
,
;
Millner,
PhD,
Lindsey
and John
A.
F&dEagSgeCr;
Carol
FRCPath,*
Parker, FRCP, FRCS,
Seymour,
a
but
cardiac
failure is
Renal
Background:
surgery.
occurrence of
recognized,
are
infrequent, complication following
a
and
concern is that the
The causes for this condition
multifactorial,
failure is
major
associated
acute renal
still
with
a
rate.
high mortality
postoperative
renal
andMaterials: We
cardiac
acute
failure
in 4patients after
occurring
Methods
report unexpected
a
Each
was
fibric acid derivative at the time of
patient
rapidly
taking
days
surgery.
uncomplicated
failure occurred
within
3
of
and was associated with
surgery
Renal
surgery.
skeletal muscle-derived creatine kinase
a
One
devel-
increased concentrations of
(CK).
patient
and another
malignant
receiving
failure after cardiac
developed
syndrome.
medications could be at
oped myoglobinuria,
hyperthermia-like
that
Conclusions: Thesecases show
lipid lowering
patients
renal
acute
This
merits
association
that
of
risk
surgery.
higher
developing
if
studies
would
careful evaluation in
and,
large prospective
proved,
suggest
patients
either
or
should discontinue
so before cardiac
statins
fibrates
taking
doing
fibrates,
surgery.
statins.
words: acute renal
failure,
Key
rhabdomyolysis,
The beneficial effects of treatment of
Case
hyperlipid-
Reports
emia in the
heart
of ischemic
secondary prevention
well established
I
Case
are
disease
(1-5).
Although lipid-
A
man with combined
such
fibric
derivatives
acid
as
61-year-old asymptomatic
was admitted for
(fi-
coenzyme
lowering agents,
elective
an-
and
hypercholesterolemia
brates)
3-hydroxy-3-methylglutaryl
after
A
reductase
are
coronary
coronary artery
giography,
grafting
bypass
(HMG-CoA)
tolerated and have
inhibitors,
generally
which
done
7
shown severe
confirmed
monthsbefore the
well
are
a
surgery,
they
signifi-
good safety profile,
development
Echocardi-
had
vessel disease.
associated with
which
of
triple
good
rarely
myopathy,
function.
left ventricular
100
cant
in
result
ography
may
rhabdomyoly-
He had been
sis
and acute renal
4
failure. Here wereport
during
mg/d
operation,
taking ciprofibrate
patients
with
a
the
4
months
The
before
de-
cardiac
who
surgery.
undergoing
uncomplicated
surgery
de-
the left anterior
vein
left
internal
to
in the
acute renal failure
mammary
and
graft
veloped
postoperative
early
with
unexpected
period,
elevated
to the
he
which was associated
graft
scending artery
saphenous
uneventful.
the first
was
However,
of
kinase
creatine
levels
right coronary artery,
(CK).
was
markedly
became
One
other
feature commonto all these
hypotensive during
postoperative
patients
mm
of
with
a
blood
80
that
all
were
fibric acid derivatives before
Hg
night,
systolic
pressure
12
taking
ad-
and
(urine
mL/h),
despite
oliguria
equate
subsequent
output
surgery.
His
12 cm
of
central venous
H20.
pressure
included infusion
with do-
management
From
thoracic
the
*Division
and the &Cdaargdgieor-;
School, London,
Division of
Sciences
of Cardiological
the
he
of
and frusemide. Over
colloid, mannitol,
course ofthe first andsecond
pamine,
St.
Medical
UK.
Unit,
George’s Hospital
Professor C.A.
days,
evening
Reprint
postoperative
the
requests:
St.
Cardiologi-
Seymour,
Medical
cal
Cranmer
Sciences,
Terrace,
School,
George’s Hospital
had
the
and
day
during
continuing oliguria,
London
SW17
0RE.
a
he suffered
second
respira-
analysis
postoperative
arrest. Results of arterial blood
gas
tory
33
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34
2
Case
were
event on
4.4
this
0.7
before
pH
immediately
Fio2
andbase
9.5
deficit,
catheterization indicated
7.19;
kpa; PC02,
kpa;
P02,
woman
A
with
1
-13.5.
58-year-old
long-standing type
mass
Pulmonary artery
and
diabetes mellitus
of 21 mm
index,
41)
months be-
obesity
(body
Hg (systolic)
artery pressure
pulmonary
with unstable
7
and mm
with
a
angina.
presented
fore
Eight
(diastolic)
artery
pulmonary
car-
Hg
she had had
an
angiography,
confirmed 2-vessel
anterior
and the
mm
of
9
surgery,
myocardial
Hg,
cardiac index
wedge capillary pressure
infarction.
done
6
months
2.4
was
was 4.31
diac
Coronary
operation,
L/min,
output
the
before
and
was480
He
and
vascularresistance
disease,
left ventricular
L/min/m2,
dynes
systemic
showed
sec - CM-5
echocardiography
good
900-1400).
(normal
range,
also had
function. She
combined
treated for
and
third
times
with noradrenaline
hypercholesterol-
required inotropic support
which had been
with
months
3
Six
of
the
was commenced on hemofiltration. On
emia,
200
twice
an
bezafibrate
before
the CKwas
than 10
greater
mg
daily.
episode
days
severe chest
day,
postoperative
she suffered
later myoglobin
and
a
the limit of
normal,
surgery,
day
upper
was detected
and
a
CKof 600 IU/L
was noted.
a left internal
The
a
full
in the urine. Hewenton to make
pain,
tion,
opera-
to the
with
are summa-
Results of his
mammary graft
recovery.
rized in
investigations
left anterior
1. He was
from
proximal
together
descending coronary artery
Figure
taking ciprofibrate
discharged
with
hospital
with
a
vein
to the first
100
a
recorded
saphenous
graft
the circumflex
mg daily
obtuse
branch of
in-
was
CK level of 261 IU/L. When
creased to 200
marginal
coronary
the time of transfer from
ciprofibrate
was uneventful. At
was with-
this dose
an
artery,
(before
mg/d
market),
a
atrial
she had
left
14 mm
of
the
there was
drawnfrom
increase in
bypass,
Hg,
pressure
asymptomatic
atrial
of 12
mm
mm
a
and
a
dose
whenthe
which fell to normal
CK,
right
pressure
of
Hg,
systolic
blood
100
In the
was reduced to 100
He was
pressure
Hg.
early postop-
subsequently
mg/d.
erative
mm
her blood
to 75/50
in-
an HMG-CoAreductase
to
simvastatin,
period,
pressure dropped
changed
and she became
an
un-
of
and he has had no
hibitor that he tolerated
well,
Hg,
hemodynamically
infusion
to
5
of
further
stable,
requiring
up
>g/min
problems.
in four
Normal
for
urea
creatinine
in
Note
that,
in
and CKlevels
1.
urea, creatinine,
mmol/L),
mg/dl]
activity
(2.5-8
patients.
range
Fig.
changes
Postoperative
8-22
creatinine:
the
in
in males and 30-180
0.6-1.2
CK
IU/L
females). [BUN:
(30-250
(60-110 wmol/L),
mg/dl,
that
skeletal
reflected
of
increased
all
isoform
showed low
CK-MB,
(<15%)
proportions
indicating
patients,
analysis
*CAVH,
Hemofiltration.
muscle
Continuous Arteriovenous
damage.
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35
arterial
well
blood
a
showed metabolic
was
Her urine
time,
adrenaline.
maintained
artery
gas analysis
initially
output
and
with
7.31
and
acidosis
base deficit -7.8. The
between
mL/h.
100
30
Pulmonary
pH
creatinine
serum
was noted to have increased two-
with the
catheterization on the first
a
day
Hg
mm
postoperative
fold when
42 mm
26
of
showed
compared
326
previous preoperative
pulmonary artery pressure
and serum
potassium
and 19 mm
values,
mmol/L,
mmol/L. His liver
reaching
7.2
was
(mean,
beats/min
(diastolic)
was 3.81
Hg
(systolic)
with
vas-
transaminases were
the
cardiac
and
output
Hg),
noted to increase more than
of normal. Heunderwent
mine infusion was restarted.
the
level
20-fold
index of2.11 beats/min/m2.
cardiac
a
upper
and
Systemic
second -
was
resistance
1220
cular
and
second
° cm-5,
hemofiltration,
dopa-
dynes
°
126 dynes
Echocardiography
was
vascular resistance
pulmonary
an
biventricular
with no
function
CM-5
showed
cardial effusion.
150-250).
good
(normal
peri-
range,
venous
Despite
oli-
hemo-
catheterization
central
she became
Pulmonary
artery
pressure,
adequate
him
showed
nous
to be well
with
a central ve-
and
<20
mL/h)
perfused
(urine
required
output,
guric
of
cm
the CK
limit of
16
Hesubsequently made
H20.
Onthe second
filtration.
day,
upper
pressure
postoperative
a
full
and his liver
returned to
the
to
than
times
a
more
10
increased
normal
and
recovery,
normal. The results of his
enzymes
are
shown
initial
She made
1).
investigations
(Fig.
good
progress,
in
1.
fifth
de-
hemofiltration was discontinued on the
Figure
2
she
However,
later,
days
day.
postoperative
andre-
mediastinitis and sternal dehiscence
4
veloped
Case
defect. The
a
muscle
to close the sternal
are shown
flap
quired
A
man
elective
coro-
was admitted for
grafting. Coronary
1.
her
in
of
results
61-year-old
Figure
investigations
nary artery
bypass
angiography,
5
the
done months
showed
before
triple-
operation,
Case
3
disease with
left
function.
ventricular
vessel
good
months before
the
3
he had been
man
with aortic stenosis
coro-
A
During
surgery,
vein thrombosis of the
69-year-old
a
presented
warfarin after
He also had
a
mm
with
of65
and
taking
deep
combined
gradient
Hg
triple-vessel
left
a
of
disease. Hehad
a
type
the
leg.
hypercholesterol-
history
nary artery
2
10-year
for which he was
He underwent
100
diabetes mellitus and had
insulin for
emia,
d.
mg/
taking
ciprofibrate
required
vascular
18 months. He had
had
coronary artery
mammary artery grafting
grafting
bypass
preceding
peripheral
with left
the
to
internal
disease and
previously
undergone angioplasty
left anterior
and short
of several
and 2
arteries,
descending artery
saphenous
peripheral
percutaneous
one of which
vein
the first
obtuse
and
transluminal
had included
to
grafts
right
coronary
marginal
angioplasties,
im-
40%
arteries. Hecame off
rotablation. Cardiac
uneventfully,
bypass
coronary
but it was noted that he
angiography
a
more colloid than
central venous
residual
before
showed
required
mediately
surgery
to maintain an
in the
stenosis in the
minor residual
expected
pressure
second
right coronary artery,
adequate
left
a
and
On the
anterior
disease,
early
postoperative period.
descending coronary artery
had
he
became
blocked small circumflex
He
postoperative day,
pyrexial
coronary artery.
been
lower back
of
noted
have
and
to
combined
confused,
(38.2°C),
complained
hypercholesterolemia,
which
He
a
arrest and was
he was
dur-
then suffered
was treated with
200
ciprofibrate
mg/d
pain.
respiratory
the
ventilated
8
months before
withdrawal of
was before
the formu-
after resuscitation.
ing
(that
Initially
surgery
to be in
because cardiac
ciprofibrate 200 mgfrom
shock,
a
thought
septic
At
studies indicated
cardiac
of 10
the aortic valve was
Edwards
lary).
output
resistance of 300
to 34
operation,
replaced
xeno-
output
L/min with
with
a
a
25-mm
vascular
systemic
Carpentier
porcine
cold
with
second - cm-5 . Herequired
blood
graft
mild
J..Lg/min
using
dynes
up
antegrade
hypothermia
cardioplegia
main-
and
noradrenaline and
adrenaline to
to
13.3
28°C.
3.5
and
(at
Dopamine
[Lg/
jjLg/min
tain
mm
con-
blood
100
above
was used while he was on
for 24 hours
kg/min)
systolic
Hg
bypass
pressure
renal failure.
tinued
Echocardiography
function,
and
pancreas
postoperatively. Twenty-four
rapidly developed
hours
ultra-
and
he became
blood
showed
sound examination ofthe
left ventricular
later,
hypotensive (systolic
good
was
85 mm
with
pressure,
(urine
oliguria
output,
pres-
He also
kidneys
Hg)
an
<30
normal.
failed to
central venous
mL/h)
Microbiological
investigations
despite
adequate
sure
and
He
40.2°C
over
without evidence of blood loss.
identify any
organisms.
significant pathogenic
remained
with
a
of severe chest
breathlessness,
complained
and
pyrexial
temperature
pain,
antibiot-
which
associ-
administration of broad
muscle
were
generalized
aches,
despite
ics.
spectrum
ated
with
a
this
from the second
serum CKlevel of 3758 IU/L. At
ofblood
analysis
Retrospective
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36
with
is associated
IU/L.
was 4383
which is
in
a
showed CK
could not be
eosinophilia,
previously
diagnos-
patients
day
myoglobin
postoperative
Urine
clue
tic
because
measured,
reported
many
The absence of
rhab-
of
hemo-
this
the
latter feature in
anuric before
our
had become
he
(10,11).
diagnosis
makes
this cause
ofrenal failure
can
He underwent
was considered.
patients
unlikely.
domyolysis
the definitive
His
be
made
and his
settled.
However,
filtration,
diagnosis
investigations
only
pyrexia
renal
renal
which was
not
who recovered
in
in
in
1. Deterioration
our
are summarized
by
biopsy,
Figure
appropriate
and 15 was caused
from ARF.
10
function between
by
patients
fully
days
Even
all
cath-
an
with
to
associated
sepsis
though
reported
urinary
patients
indwelling
appeared
have at least
1
of the
risk
as do
no
and was
factors for
recovered
eter. Hesubsequently
discharged
developing
who re-
without further events.
ARF,
surgery,
account for the massive
common feature
postoperative
many
patients
cardiac
quire
risk factor
would
which was
of
single
elevation of
CK,
development
Discussion
a
to all
and the
after
in
of acute renal failure
varies from 2.5% to
1.
The
(ARF)
7%,
rhabdomyolysis
Measurement of
patient
prevalence
cardiac
mor-
with
a
CKis
sensitive in-
surgery
circulating
in
of
muscle
In our Renal
dicator
70%
from 24%to
Human
tissues contain
3
Unit,
(6,7).
damage.
which are
tality
1998,
forms of
muscle
acute renal failure
the incidence of
made
of dimers of the
CK,
and
requiring
up
isoforms:
in
brain
hemofiltration
continuous arteriovenous
and
MM, BB,
(CAVH)
(M)
(B)
2%.
Skeletal
was
MB.
muscle
cardiac
contains
only
CK-MM,
mostly
undergoing
surgery
patients
the
in all of
with less than 15%
CK-MB. In the
most CK CK-MB.
CAVH was initiated
Because
rapidly
precluded
myocardium,
is
this
here,
confirmatory
indices of ARFsuch
reported
patients
At the time of
were
of other
all
of
measurement
our
de-
urinary
surgery,
fibrates
patients
urine osmo-
sodium,
excretion of
scribed
the fractional
as
or bezafi-
taking
treatment for
(ciprofibrate
as
osmolality,: andurine creatinine/serum
combined
brate)
lality/plasma
hypercholesterol-
num-
a
emia. Theprincipal
have identified
creatinine. Previous studies
mechanism ofaction offibrates
the
risk of
to lower
is
of factors associated with an increased
ber
(TG)
plasma triglyceride
by
promo-
restrict-
ARFin
tion of
of TG-rich
of free
and
undergo-
patients
lipolysis
developing postoperative
lipoprotein
melli-
These include diabetes
cardiac
acids for
of
surgery.
renal
ing availability
fatty
ing
tus,
low
synthesis
advanced
in the liver
TG
The
half-life of indi-
(12).
vidual fibrates varies. The
age,
impairment,
urine and
preexisting
intraoperative
output
emergency surgery
plasma
half-life ofbezafibrate is
preoperative
and
output,
4
to
2
low cardiac
whereas for
it is much
hours,
requiring inotropic support
(7,8).
ciprofibrate
In most
evi-
(80-120 hours) (13).
longer
dence of muscle
instances,
fail-
with acute renal
associated
severe
whether in
of
the form
Rhabdomyolysis
damage,
of cardio-
ure is
a
or as
in
elevation
CK,
recognized
complication
myalgic symptoms
appears
but can occur in
within
2
months of
of
commencement of
al-
surgery
patients
during
bypass
pulmonary
therapy,
was used
an aortic balloon
Other
in whom
or
24
even
months have
5, 6, 8,
though delays
pump
be
va-
contributory factors may
described
the
been
(9).
low cardiac
(14).
operation
and the
The
mechanism
the
fibrates cause
syndrome
high-dose
alpha
output
effect of
precise
damage
whereby
intra-
continuous
muscle
is
not
soconstrictor
of
the risk
known; however,
intrave-
venous infusion of
is
cir-
increased in certain
However,
to cause
epinephrine.
reported
developing myopathy
is
cumstances. Renal
nous
risk
the
increases
rhabdomyoly-
epinephrine
insufficiency
in cardiac
where there is direct
sis
of
because
fibrates are
elimi-
only
surgery
of the femoral
myopathy
principally
the
for
nated
the
cannulation
had
Three of our
cardiopul-
artery
by
kidneys.
patients
with
pro-
and it also correlates
circulation
but
mild
renal
It has been
monary
bypass,
preexisting
impairment.
established that
at
a
of 200
during surgery,
leg ischemia/reperfusion-
mg
with
been
longed extracorporeal
ciprofibrate
dosage
which
induced
to
cause
or more
per day
is
believed
to be associated
might
These conditions did not
increased risk of
has
and
one of our
(9).
injury
pertain
post-
was re-
rhabdomyolysis
2
who
received
and
withdrawn at this dose.
4,
epinephrine
patients
Only
taking
patients
an elevated CK
had
been
200
Furthermore,
3)
mg/d
(patient
before
operatively.
ciprofibrate
1)
developed
an
4
in
before intravenous
Another
epinephrine
surgery.
ported
patient
(patient
was commenced.
elevation in
rechal-
but
when
CK
asymptomatic
with
plasma
renal disease is another
Atheroembolic
at
a
dose of 200
potential
lenged
ciprofibrate
100
mg/d
it
for renal failure after vascular
and
not when
cause
surgery,
given
mg/d.
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37
renal
and
function
to ad-
metabolites are
Fibrate
(greater
(13).
rhabdomyolysis secondary
predominantly
ministration of statins with
itraconazole
such as
in the blood
bound
drugs
erythro-
than 90%)
the
In
plasma protein
of other
and nefazodone
that are
(37),
well
(38),
(39)
mycin
is now
pro-
metabo-
drugs
possibility
perhaps
plasma
presence
bound,
established.
are
This is because statins
metabolized in the liver
the microsomal
there
a
that these
increasing
is
tein
ac-
be-
as
their
be
lites
cyto-
by
may
In
displaced,
chrome P450 located in the smooth
reticulum of the
clinical
the interaction
endoplasmic
only
practice,
~ivity.
tween
an in-
Thus,
(40).
such
fibrates and coumarin derivatives
hepatocytes
creased
ex-
al-
likelihood of
be
adverse events
is believed to be of
warfarin
(15),
might
significance
case of
if statins are
coadministered with
ofthe CYP3A4
there was
one
rhabdomy-
conjunction
pected
any agent
isoenzyme.
reported
was
though
that inhibits the
in
when
activity
given
ciprofibrate
olysis
In the
absence of other identifiable factor that
to
In addition
with
(16).
pa-
vein
any
ciprofibrate,
ibuprofen
account for the clinical events and the rise in
a
had
warfarin for
4
been
tient
might
the measured
deep
taking
surgery,
ofthe fibrate could have
the
al-
the
factor com-
medication.
that
it
before
and
is
thrombosis
pharmacokinetics
CK,
circulating
only
possible
4
mon to all
Each
was the
been
fibrate
patients
was
on
different combi-
a
of this.
in
as
a
tered
patient
operated
by
Similarly,
hypo-
the
consequence
nation of
practices.
and under different consultant
used in induction and
states such as
syndrome,
surgeons
The
nephrotic
proteinemic
increased
is
of fibrate-induced
risk
agents
during
myopathy
the
free
to
anesthesia varied. Two
2
an
and
4)
available to bind
less
because
is
patients
(patients
(17,18),
active
protein
received
levels of
suxamethonium at
thus
the
induction,
known to cause transient 2- to
metabolites,
agent
increasing
in
elevation
3-fold
drug
Hypothyroidismis also believed
active
(13).
in
and has been
with
associated
the risk of
of
increase
CK,
rhabdomy-
rarely
development
myopathy
was no
this serious
with
with fibrates
There
association
However,
occurs in
(41,42).
(19-22).
olysis
complication
our
muscle
evidence of
in
of
any
clinical
usually
patients
preexisting
hypothyroidism
arrest
and
who
rhab-
disease
Both intermittent ischemic
arrest were
one
1,
(42,43).
developed
patients,
(patient
func-
and cold blood
had
documented normal
cardioplegic
employed
thyroid
domyolysis)
varied
tion tests
6
months
intraoperatively. Oxygenators
throughout
previously.
rhab-
of
this
used
for
sedation
There are
cases in the literature of
period. Agents
reported
postoperative
in the
but none received
associated
muscle
with
varied,
initial
domyolysis
monotherapy
paralysis
drug
group
either the
with
or
a
combi-
There is no
fibrate or statin
postoperative period.
reported
general
the risk
association between
and
fibrates, statins,
nation of these
However,
(23-35).
drugs
anesthetic
relevant to the
be
to be rare in that
for
1
case has
which
appears
been
agents,
this
might
approximately
in
at the
of the Unit
The
100,000
reported
every
treatment-years
recorded cases
patients
report.
policy
Table
1
time was that all
received
a
dose of
shows the number of
(36).
patients
single
and the incidence
vidual
with indi-
intravenous cefuroxime with the induction of anes-
of
rhabdomyolysis
thesia
but
surveil-
as
wound
to
infection,
taking any nephrotoxic
drugs according
prophylaxis against
postmarketing
lance.
none of the
were
patients
There were
when statins
antibiotics before
notable interactions
with
Thus,
drug-induced
surgery.
were
are
acute
the
to
of
used in
that
interstitial
other
does not
any
conjunction
drugs
nephritis
apply
metabolized in
a
similar manner. Deterioration of
patients.
and the Incidence of
Fibrates andStatins
Table 1. The Numberof
Cases
for Different
Rhabdomyolysis
Reported
were obtained
contact with
the
NOTE. These are world-wide
*
and
through personal
figures
drug companies.
1995
involved
and 71 involved
This
includes cases from
to
1985
(31
figure
ciprofibrate 100 mg
ciprofibrate
200
La Revue Prescrire
151.
1995;
mg)
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