Kidney nontumor
Drug induced tubulointerstitial disease
Rhabdomyolysis

Senior Author: Nicole K. Andeen, M.D.
Editor-in-Chief: Debra Zynger, M.D.
Amanda Breitbarth
Nicole K. Andeen, M.D.

Topic Completed: 25 March 2019

Revised: 2 October 2019

Copyright: 2019, PathologyOutlines.com, Inc.

PubMed Search: Rhabdomyolysis[TI] kidney[TI] free full text[sb]

Amanda Breitbarth
Nicole K. Andeen, M.D.
Page views in 2019 to date: 608
Cite this page: Breitbarth A, Andeen NK. Rhabdomyolysis. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/kidneyrhabdomyolysis.html. Accessed November 12th, 2019.
Definition / general
  • Acute tubular injury with myoglobin+ tubular casts seen in setting of rhabdomyolysis
Essential features
  • Acute tubular injury with myoglobin+ tubular casts
  • Seen in setting of rhabdomyolysis; also has elevated serum creatine kinase
Terminology
  • Also called pigment nephropathy
ICD coding
Epidemiology
Pathophysiology
Etiology
  • Rhabdomyolysis results from muscle injury (Crit Care 2014;18:224):
    • Traumatic: crush injury, exercise, seizure
    • Drug related: cocaine, heroin, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) inhibitors, rapamycin, oseltamivir (Transplantation 2006;82:645)
    • Toxic: clostridial toxin, snake venom
    • Malignant hyperthermia
    • Electrical current
Diagrams / tables

Images hosted on other servers:

Pathophysiology

Therapeutic
approaches

Clinical features
Laboratory
  • Urinalysis: dipstick positive for heme protein, no erythrocytes, dark pigmented casts on urine microscopy
  • Elevated creatine kinase, often > 100,000 U/L
  • Elevated creatinine
  • Electrolyte abnormalities: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
  • Reference: Crit Care 2014;18:224
Prognostic factors
  • Time to diagnosis and treatment
  • Age (younger patients have better recovery)
  • Reference: Crit Care 2014;18:224
Case reports
Treatment
Microscopic (histologic) description
  • Acute tubular injury: loss of brush borders, attenuation and sloughing of epithelium
  • Granular or pigmented casts in tubules
  • Interstitial edema
  • Glomeruli spared
Microscopic (histologic) images

Contributed by Mazdak Khalighi, M.D. and Nicole K. Andeen, M.D.

Acute tubular injury with pigmented, granular and focally stringy appearing casts

PAS


Myoglobin

Immunofluorescence description
  • Negative immunofluorescence
Positive stains
  • Myoglobin immunohistochemistry highlights casts
Electron microscopy description
  • Casts have electron dense granules
Sample pathology report
  • Native kidney biopsy:
    • Myoglobin cast nephropathy
    • Comment: consistent with the clinical history of acute kidney injury and rhabdomyolysis in this patient, kidney biopsy demonstrates acute tubular injury / acute tubular necrosis with associated myoglobin positive casts, characteristic of myoglobin cast nephropathy
Differential diagnosis
  • Hemoglobinuria:
    • May have similar appearing pigmented casts
    • Casts are negative for myoglobin and positive for hemoglobin by IHC
  • Light chain cast nephropathy:
    • Has atypical "fractured" or "cracked" casts with cellular reaction
    • Strong light chain staining bias (kappa or lambda) by immunofluorescence
    • Casts are negative for myoglobin by IHC
  • Other acute tubular injury, including toxic or ischemic:
    • Also has acute tubular injury with granular debris in tubular lumen
    • Normal serum creatine kinase
    • Casts are negative for myoglobin by IHC
Board review question #1
A patient presents with acute kidney injury and renal biopsy demonstrates acute tubular injury. Tubular casts stain with myoglobin by immunohistochemistry. What plasma enzyme will be elevated and what is the correct clinical diagnosis?

  1. Creatine kinase; rhabdomyolysis
  2. Creatinine; multiple myeloma
  3. Lactate dehydrogenase; paroxysmal nocturnal hemoglobinuria
  4. Troponin; myocardial infarction
Board review answer #1
A. Creatine kinase; rhabdomyolysis

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Board review question #2
A kidney biopsy shows acute tubular injury and myoglobin stain is positive in tubular casts. What is the most likely clinical history for the patient?



  1. Dehydration
  2. Multiple myeloma
  3. Rapidly progressive glomerulonephritis (RPGN)
  4. Trauma, extreme physical exercise or prolonged immobilization
Board review answer #2
D. Trauma, extreme physical exercise or prolonged immobilization

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