Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise

Table 1 Differential diagnosis of acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise and myoglobinuria acute renal failure

	ALPE	Myoglobinuria acute renal failure
Amount of exercise	+	+++
Type of exercise	Anaerobic exercise	Aerobic exercise
Urine volume	Non-oliguria	Oliguria
Reddish brown urine	-	+++
Loin pain	+++	-～+
Nausea, vomiting/slight fever	++	+-
Dehydration	+	+++
Serum CK/serum myoglobin	normal or mildly elevated	↑↑↑

ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; CK: Creatinine kinase.

Table 2 Clinical findings in 57 patients with acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise, n (%)

Age (yr)	22.09 ± 9.55 (13-65)
Sex	Male 52 (91.2%), female 5 (8.8%)
Exercise	47/57 (82.5)
Fever	19/57 (33.3)
Nausea/vomiting	36/57 (63.2)
Loin pain	36/57 (63.2)
Abdominal pain	32/57 (56.1)
High blood pressure on admission	10/30 (33.3)
High CRP on admission	13/18 (72.2)
Serum creatinine on admission (mg/dL)	4.81 ± 2.25 (1.08-12.1), n = 56
Serum myoglobin on admission (ng/mL)	86.46 ± 66.80 (10-260), n = 21
Serum CK on admission (IU/L)	272.76 ± 301.97 (38-1182), n = 47
Kidney CT patchy findings	32/40 (80)
Hemodialysis	10/54 (18.5)
Hydration	37/54 (68.5)
Hydration+drugs	6/54 (11.1) [furosemide (2), dopamine (2), nicardipine (1), Vitamin C, E (1)]
Rest	1/54 (1.9)
Renal hypouricemia	31/57 (54.4)
Recurrence of ALPE	14/54 (25.9)
Days of renal failure improvement	17.4 ± 10.4 (d), n = 35
Premedication	5/26 (19) [vasopressor (2), NSAIDs (1), Antibiotic agent (1), epileptic drugs (1)]

Values are expressed with mean ± standard deviation with (range) or the number of positive cases with (percent). ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; CRP: C-reactive protein; CK: Creatinine kinase; CT: Computed Tomography; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 3 Comparison of characteristics in acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise, n (%)

	This cases	Ohta et al[31], 2004	Ishikawa et al[30], 2002
Age (yr)	22.1 ± 9.6 (13-65)	19.3 ± 8.1 (11-46)	22.0 ± 7.6 (10-54)
Sex (male)	52/57 (91.2)	48/54 (88.9)	112/118 (94.9)
Fever	19/57 (33.3)	7/60 (11.7)	38/47 (80.9)
Nausea/vomiting	36/57 (63.2)	51/60 (85)	84/88 (95.5)
Loin pain	36/57 (63.2)	35/60 (58.3)	NA
Abdominal pain	32/57 (56.1)	22/60 (36.7)	NA
Serum creatinine on admission (mg/dL)	4.81 ± 2.52 (N = 56)	NA	4.70 ± 2.90 (N = 77)
Kidney CT patchy findings	32/40 (80)	NA	49/96 (92)
Hemodialysis	10/54 (18.5)	NA	20/118 (16.9)
Exercise	47/57 (82.5)	61/61 (100)	118/118 (100)
Renal hypouricemia	31/57 (54.4)	48/48 (100)	49/96 (51)
Recurrence of ALPE	14/54 (25.9)	13/54 (24.1)	20/118 (16.9)
Days of renal failure improvement	17.4 ± 10.4 (N = 35)	NA	13.1 ± 8.3 (N = 87)

Values are expressed with mean ± standard deviation with (range) or the number of positive cases with (percent). ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; CT: Computed Tomography; N: Number of patients; NA: Not available.

Table 4 Comparison of characteristics in acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise with and without renal hypouricemia, n (%)

	Renal hypouricemia	No renal hypouricemia
Number of patients	31	26
Age (yr)	21.6 ± 10.7 (11-65)	22.7 ± 8.0 (13-49)
Sex (male)	28/31 (90)	24/26 (92)
fever	7/31 (23)	12/26 (46)
Nausea/vomiting	22/31 (71)	14/26 (54)
Loin pain	21/31 (68)	15/26 (58)
Abdominal pain	14/31 (45)	18/26 (69)
High blood pressure on admission	6/21 (28.6)	4/9 (44.4)
High CRP on admission	9/14 (64.3)	4/4 (100)
Serum creatinine on admission (mg/dL)	4.53 ± 2.04 (N = 30)	5.24 ± 2.81 (N = 26)
Serum CK on admission (IU/L)	261 ± 304 (N = 26)	269 ± 225 (N = 21)
Kidney CT patchy findings	9/15 (60)	23/25 (92)
Hemodialysis	7/29 (24)	2/25 (8)
Exercise	29/31 (94)	19/26 (73)
Recurrence of ALPE	11/28 (39)	3/26 (12)
Days of renal failure improvement	17.9 ± 8.3 (N = 26)	16.1 ± 15.3 (N = 10)
premedication	2/20 (10)	3/6 (50)

Values are expressed with mean ± standard deviation with (range) or the number of positive cases with (percent). ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; CRP: C-reactive protein; CK: Creatinine kinase, CT: Computed Tomography; N: Number of patients.

Table 5 Comparison of characteristics in acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise with and without renal hypouricemia, n (%)

	Renal hypouricemia, this cases	Renal hypouricemia, Ishikawa[32], 2014	No renal hypouricemia, this cases	No renal hypouricemia, Ishikawa[32], 2014
Number of patients	31	148	26	94
Age (yr) median	18 (11-65)	18 (15-25)	21 (13-49)	19 (16-26)
Sex (male)	28/31 (90)	136/148 (92)	24/26 (92)	82/92 (89)
Fever	7/31 (23)	35/43 (81)	12/26 (46)	35/49 (71)
Nausea/vomiting	22/31 (71)	106/107 (99)	14/26 (54)	63/66 (95)
Serum CK on admission (IU/L)	155 (44-1182), N = 26	212 (100-447), N = 81	225 (38-686), N = 21	317 (124-696), N = 70
Serum creatinine on admission (mg/dL)	4.2 (1.1-8.9), N = 30	4.3 (2.6-6.7), N = 122	4.7 (1.4-7.6), N = 26	3.2 (2-5.1), N = 75
Kidney CT patchy findings	9/15 (60)	31/32 (97)	23/25 (92)	56/58 (97)
Hemodialysis	7/29 (24)	46/148 (31)	2/25 (8)	16/94 (17)
Recurrence of ALPE	11/28 (39)	38/148 (26)	3/26 (12)	7/94 (7)
Days of renal failure improvement (d)	17 (6-30), N = 26	14 (10-19), N = 85	15 (5-22), N = 10	10 (7-16), N = 66

Values are expressed with median with (range) or the number of positive cases with (percent). ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; CK: Creatinine kinase; CT: Computed Tomography; N: Number of patients.

Table 6 Clinical findings of current and previous reported cases of acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise without strenuous exercise

Patient No.	Age (yr)	Sex	Renal hypouricemia	Suspected trigger
1	14	Male	Yes	Gastroenteritis
2	30	Male	Yes	NA
3	33	Male	NR	URI and heavy alcoholconsumption
4	23	Female	NR	URI
5	25	Male	No	URI
6	32	Male	No	NSAIDs
7	30	Male	NR	NA
8	49	Male	Yes	Coincidence of myalgia
9	15	Male	Yes	Vasopressor
10	65	Male	Yes	Ureteral stone and NSAIDs

ALPE: Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise; NA: Not available; URI: Upper respiratory infection; NSAIDs: Non-steroidal anti-inflammatory drugs.