Statin-Induced Rhabdomyolysis Complicated by Acute Renal Failure Leading to Dialysis

Learning Objective #1: Recognize life changing consequences of statin induced injury in patients with stage IV CKD Learning Objective #2: Identify statin induced muscle and kidney injury CASE: 56 year old male with presents with generalized malaise, myalgias, tea colored urine and loose stools for 2 days. He denies sick contacts, flu like symptoms, fevers, recent changes in medications, dehydration or recent strenuous exercise. He is a former smoker with 35 pack years, social alcohol consumer and denies illicit drug use. His medications include: aspirin 81mg, atorvastatin 80mg and metoprolol tartrate 25mg for coronary artery disease, amlodipine 10mg for hypertension, lantus 8 units for type 2 diabetes and lasix 60mg for stage IV chronic kidney disease. On examination he was hemody-namically stable, ill appearing obese gentleman with tenderness in the major muscle groups of his upper and lower extremities. The rest of his exam was unremarkable. Laboratory studies revealed hyperkalemia at 6.2 mEq/L, creat-inine 7.70 mg/dL (baseline around 4 mg/dL), calcium 7.8 mg/dL, phosphorus 9.9 mg/dL, his serum ALT was 41 IU/L and AST was 245 IU/L. Urinalysis was significant for hematuria and proteinuria. Creatine protein kinase (CPK) peaked at 452,312. Patient was found to be in rhabdomyolysis leading to acute on chronic renal failure. Statin was removed, patient was started on continuous infusion of normal saline and furosemide drip. CPK was down trending however due to worsening hyperkalemia and hyperphosphatemia despite adequate urine output, a tunneled-cuff catheter was placed and patient was initiated on hemodialysis. Electrolytes and CPK normalized however patients renal function did not improve leading to end stage renal disease. IMPACT/DISCUSSION: Cardiovascular disease is a major cause of morbidity and mortality in the world with the prevalence of cardiovascular diseases doubling by 2020. Statin therapy is the primary pharmacologic therapy to achieve low LDL cholesterol in efforts to improve atherosclerotic cardiovascular disease outcomes in primary and secondary prevention. High doses of statins increase the risk of rhabdomyolysis. The US FDA Adverse Event Reporting System database reports that there are.3-12.5 cases out of 1 million of statin induced rhabdomyolysis. Rhabdomyolysis is syndrome where muscle pain and weakness is caused by muscle tissue breakdown with release of intramuscular contents (enzymes, myoglobin, electrolytes) into the circulation. Myoglobin is cytotoxic to renal tubules and causing tubular cast formation and acute tubular necrosis. Cytokine induced arteriolar vasoconstriction in combination with dehydration Results in decreased glomerular filtration rate and eventually acute renal failure. Conclusion: This case report is aimed to highlight the risks of high dose statin therapy and to consider a medication/dose review in the setting of advanced chronic kidney disease to prolong time to dialysis, ultimately improving quality of life