CRUSH SYNDROME AND RHABDOMYOLYSIS-ASSOCIATED ACUTE KIDNEY INJURY: NUTRITIONAL AND NATURAL THERAPEUTIC APPROACHES

Abstract

Crush syndrome (CS), also known as traumatic rhabdomyolysis, is a systemic clinical condition resulting from localized muscle compression injury. It frequently occurs following natural disasters, trauma, or industrial accidents and is associated with severe complications, including acute kidney injury (AKI), arrhythmias, sepsis, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and multi-organ dysfunction. The release of intracellular components such as myoglobin, potassium, creatine kinase, and lactic acid into the systemic circulation contributes to nephrotoxicity, electrolyte disturbances, and organ dysfunction. Among these complications, rhabdomyolysis-induced AKI is recognized as a major determinant of mortality in CS. This review comparatively evaluates conventional medical approaches and emerging natural product-based strategies for the management of CS and rhabdomyolysis-associated AKI. Evidence from the literature indicates that early and effective fluid-electrolyte therapy remains the cornerstone of treatment, playing a pivotal role in preserving renal function. The goal of nutritional management is to limit renal injury, prevent complications, and maintain metabolic stability. International guidelines (KDIGO, ESPEN) recommend an energy intake of 20–30 kcal/kg/day, with oral feeding preferred whenever feasible. When oral intake is not possible, initiation of enteral nutrition within 24 hours has been shown to be both safe and effective. In patients at high risk of refeeding syndrome, energy targets should be achieved gradually over several days. Recent experimental studies have investigated natural products such as kefir, baicalin, green propolis, and wheatgrass. Their antioxidant, anti-inflammatory, and cytoprotective properties may mitigate oxidative stress and inflammation, thereby reducing renal injury. Nevertheless, current evidence is largely limited to preclinical models, and further high-quality controlled studies are needed before these agents can be incorporated into clinical practice.

Keywords

• Crush syndrome
• rhabdomyolysis
• nephrotoxicity
• acute renal failure
• fluid resuscitation
• preventive approach

Crush Sendromu ve Rabdomiyoliz İlişkili Akut Böbrek Yetmezliği: Beslenme ve Doğal Tedavi Yaklaşımları

Abstract

Crush sendromu (CS), travmatik rabdomiyoliz olarak da tanımlanan ve kas dokusunun lokalize ezilme hasarı sonucunda gelişen sistemik bir klinik tablodur. Genellikle doğal afetler, travmalar ve endüstriyel kazalar sonrasında görülmekte olup, akut böbrek yetmezliği (ABY), aritmi, sepsis, akut respiratuar distres sendromu (ARDS), dissemine intravasküler koagülopati (DIC) ve çoklu organ yetmezliği gibi ciddi komplikasyonlarla ilişkilidir. Kas hücrelerinin yıkımıyla dolaşıma geçen miyoglobin, potasyum, kreatin kinaz ve laktik asit gibi intrasellüler komponentler nefrotoksisiteye, elektrolit dengesizliklerine ve organ disfonksiyonuna yol açmaktadır. Özellikle rabdomiyoliz ilişkili ABY, CS’de mortalite açısından en belirleyici faktörlerden biridir. Bu derleme, CS ve rabdomiyoliz ilişkili ABY’nin yönetiminde geleneksel tıbbi tedaviler ile doğal ürün temelli yaklaşımları karşılaştırmalı olarak incelemektedir. Literatür bulguları, ABY tedavisinde en kritik uygulamanın erken ve etkin sıvı-elektrolit tedavisi olduğunu, bunun böbrek fonksiyonlarının korunmasında temel rol oynadığını göstermektedir. Nutrisyonel tedavide ise amaç böbrek hasarını sınırlamak, komplikasyonları önlemek ve metabolik dengeyi sürdürmektir. Uluslararası kılavuzlar (KDIGO, ESPEN), enerji gereksiniminin 20–30 kcal/kg/gün olacak şekilde planlanmasını ve oral beslenme mümkün değilse 24 saat içinde enteral beslenmeye başlanmasını önermektedir. Refeeding sendromu riski taşıyan hastalarda ise enerji hedeflerine kademeli olarak ulaşılması gerekmektedir. Son yıllarda yapılan deneysel araştırmalar, kefir, baicalin, yeşil propolis ve buğday çimi gibi doğal ürünlerin antioksidan, antiinflamatuar ve hücre koruyucu etkileri sayesinde oksidatif stres ve inflamasyonu azaltarak böbrek hasarını hafifletebileceğini ortaya koymuştur. Bununla birlikte, mevcut veriler sınırlı olup, klinik uygulamaya geçiş için daha fazla yüksek kaliteli çalışmaya ihtiyaç vardır.

Keywords

• Crush sendromu
• rabdomyoliz
• nefrotoksisite
• akut böbrek yetmezliği
• sıvı resüsitasyonu
• koruyucu yaklaşım

References

1. Abdeen, A, Samır, A., Elkomy, A, Aboubaker,M., Habotta, OA, Gaber A, Abdelkader, A. (2021) The potential antioxidant bioactivity of date palm fruit against gentamicin-mediated hepato-renal injury in male albino rats, Biomedicine & Pharmacotherapy, 143: 112154.
2. Ayer, C., Bakır, B., Çalık, G., Yurtdaş-Depboylu, G., Yalçın, T., Kaner, G. (2023) Afet sonrası görülebilecek semptomlara yönelik beslenme önerileri, İzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi, 8(2):669-674.
3. Balah, A., Helal, H., Raslan, Na., Emran, TB., Ahmad, SF., Attı, SM., Alı, AA. (2023). Wheat Grass Attenuates Acute Kidney Injury Secondary to Rhabdomyolysis in a Rat Model of Crush Syndrome, Journal of Biological Regulators and Homeostatic Agents, 37(12): 7075-7085.
4. Candela, N., Silva, S., Georges, B., Cartery, C., Robert, T., Moussi-Frances, J., … Faguer, S. (2020). Short- and long-term renal outcomes following severe rhabdomyolysis: a French multicenter retrospective study of 387 patients, Annals of Intensive Care, 2020;10:27.
5. Cano, N., Aparicoi, M., Brunorı, G., Carrero, J., Cianciaruso, B., Fiaccadori, E., Lindholm, B., Teplan, V., Fouque, D., Guarnieri, G. (2009). ESPEN Guidelines on Parenteral Nutrition: adult renal failure, Clinical Nutrition, 28(4):401- 414.
6. Fiaccadori, E., Sabatino, A., Barazzoni, R., Carrero, JJ., Cupisti, A., De-Waele, E., Jonckheer, J., Singer, P., Cuerda, C. (2021). ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease, Clinical Nutrition, 40(4):1644-1668.
7. Genthon, A., Wilcox, Sr. (2014). Crush syndrome: A case report and review of the literatüre, J Emerg Med., 46:313.
8. Hebert, JF., Burfeind, KG., Malinoski, D., Hutchens, MP. (2022). Molecular Mechanisms of Rhabdomyolysis-Induced Kidney Injury: From Bench to Bedside, Kidney International Reports, 8:17– 29

9. Kang, HG., Lee, HK., Cho, KB., Park, SI. (2021). A Review of Natural Products for Prevention of Acute Kidney Injury, Medicina (Kaunas, Lithuania), 57: 1266.
10. Karabacak, P., Solmaz, Fa., Gultekın, F., Oncu, M., Yuksel, O., Ozgoçmen, M., Ilhan, I. (2016). The effectiveness of kefir in acute renal failure due to glycerol-induced rhabdomyolysis, Int J Clin Exp Med., 9(9); 17919-17925.
11. Kodadek, L., Carmichael, SP., Seshadri, A., Pathak, A., Hoth, J., Appelbaum, R., Michetti, CP., Gonzalez, RP. (2022). Rhabdomyolysis: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document, Trauma Surg. Acute Care Open, 2022;7:e000836.
12. Liu, X., Liu, J., Zhang, Q., Sun, Q., Wang, X. (2010). Clinical features and prognostic analysis of crush syndrome caused by Wenchuan earth-quake, Chinese Journal of Traumatology, 13(6):333-338.
13. Luo, Y., Liu, C., Li, D., Yang, B., Shi, J., Guo, X., Fan, H., Lv, Q. (2023). Progress in the Diagnostic and Predictive Evaluation of Crush Syndrome, Diagnostics (Basel, Switzerland). 13:3034.
14. Lv, Q., Long, M., Wang, X., Shi, J., Wang, P., Guo, X., Song, J., Midgley, AC., Fan, H., Hou, S. (2021). The Role of Alpha-1-Acid Glycoprotein in the Diagnosis and Treatment of Crush Syndrome-Induced Acute Kidney Injury, Shock, 56:1028–1039
15. Mahmood, YS., Kathem, SH. (2023) Protective effect of citronellol in rhabdomyolysis-induced acute kidney injury in mice, J Med Life., 16(7):1057-1061.
16. Mardones, A., Arellano, P., Rojas, C., Gutierrez, R., Oliver, N., Borgna, V. (2016). Prevention of crush syndrome through aggressive early resuscitation: clinical case in a buried worker, Prehosp Disaster Med., 31(3):340-2.
17. Mcknight, C., Newberry, C., Sarav, M., Martindale, R., Hurt, R., Daley, B. (2019). Refeeding syndrome in the critically ill: a literature review and clinician’s guide, Curr Gastroenterol Rep., 21:1-7.
18. Reber, E., Friedli, N., Vasiloglou, MF., Schuetz, P., Stanga, Z. (2019). Management of refeeding syndrome in medical inpatients, J. Clin. Med., 8(12):2202.
19. Sever, MS., Vanholder, R. (2012). Recommendations for the management of crush victims in mass disasters, Nephrology Dialysis Transplantation, 2012;27(Suppl1): i1-i67.
20. Silveira, MA., Capcha, JM., Sanches, TR., Desousa-Moreira, R., Garnica, MS., Shimizu, MH., … Andrade, L. (2021). Green propolis extract attenu- ates acute kidney injury and lung injury in a rat model of sepsis, Scientific Reports., 2021;11: 5925.
21. Song, SJ., Kim, SM., Lee, SH., Moonjy-Hwang, HS., Kım, JS., … Kim, YG. (2020). Rhabdomyolysis-Induced AKI Was Ameliorated in NLRP3 KO Mice via Alleviation of Mitochondrial Lipid Peroxidation in Renal Tubular Cells, International Journal of Molecular Sciences, 21:8564.
22. Thibault, R., Abbasoglu, O., Ioannou, E., Meija, L., Ottens-Oussoren, K., Pichard, C., Rothenberg, E., Rubin, D., Siljamäki-Ojansuu, U., Vaillant, MF. (2021) ESPEN guideline on hospital nutrition, Clinical Nutrition, 40(12):5684- 5709.
23. Yalçınkaya-Yavuz, O., Aydogdu, N., Taştekın, E., Sut, N. (2018). The Effects of Baicalin on Myoglobinuric Acute Renal Failure in Rats. Balkan Med J., 20;35(1):68-76.
24. Yazıcı, R., Ilcın, C., Ozsu, T., Demırtakan, T., Kalafat, Um., Dogan, S. (2023). A Comprehensive Review for Refreshing the Crush Syndrome Knowledge After the Devastating Earthquake in Turkey, Comprehensive Medicine, 15(2):165-170.
25. Yıldırım, Ig., Toprak, K., Sanlıer, N. (2023). Crush Sendromu ve Beslenme Tedavisi, Muş Alparslan Üniversitesi Sağlık Bilimleri Dergisi, 3(3):77-83
26. Wu, J., Pan, X., Fu, H., Zheng, Y., Dai, Y., Yin, Y., … Hou, D. (2017). Effect of curcumin on glycerol-induced acute kidney injury in rats, Scientific Reports, 7:101-14.