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Acute Renal Failure in Heat Exhaustion

1977; BMJ; Volume: 123; Issue: 2 Linguagem: Inglês

10.1136/jramc-123-02-06

2052-0468

C D Pusey, C.T. Flynn, C R Winfield,

Climate Change and Health Impacts

Acute renal failure (A.R.F.) is a well recognised but rare complication of heat exhaustion due to muscular exertion.It has been estimated to occur in 2 to 9 per cent of cases (Malamud, Haymaker and Custer 1946, Leithead and Lind 1964, Austin and Berry 1956, Shibolet et al 1967, Barry and King 1962).We report a recent case, discuss the outcome of five other cases treated in the Renal Unit, Princess Mary's R.A.F.Hospital, Halton, .and consider the aetiology and prevention of this condition. Case reportA 23 year old T.A.V.R. officer, who regarded himself as reasonably fit, attempted an 11 mile forced march in full kit on a hot summer's day, during a pre-p:uachute training course.He had not taken any appreciable quantity of fluid that morning, and did not have any water during the march.He began to feel unwell at the half-way stage, but managed to carry on in a dazed condition until he collapsed 400 yards from the end.He was taken to the Cambridge Military Hospital, where he was found to be confused, sweating, peripherally cyanosed and clinically fluid depleted.The oral temperature was 39°C (rectal temperature is more accurate in these C:lses, and is usually recorded), pulse rate 140/minute, and blood pressure 90/35 mm Hg.A diagnosis of heat exhaustion was made and he was cooled and given 6 litres of intravenous fluid rapidly, with some improvement in his general condition.The urine contained numerous red cells, free haemoglobin, and some protein, but no myoglobin was detected.The initial haemoglobin was 18.1 g/dl, packed-cell volume 57•6 per cent, falling rapidly with rehydration.Urine output remained at about 1 1/24 hr, but blood urea rose from 9.9 mmol/l to 16.8 mmol/I in 2 days.He had developed non-oliguric acute renal failure.Conservative management, with a 20 g protein diet and salt and water restriction, was initiated, but as the blood urea rose to 27.3 mmol/I on the 8th day, he was transferred to the R.A.F.Renal Unit.On admission clinical examination revealed a blood pressure of 150/85, some tenderness over the muscles of the back, and diminished reflexes, but was otherwise normal.Conservative treatment was continued, and blood urea rose to 36.75 mmol/I by the 12th day.He was not dialysed as serum potassium remained normal, and he had only slight clinicll evidence of uraemia.Urine output remained at 1 1/24 hr until the 10th day, when a diuresis commenced.The blood' urea started to fall spontaneously from day 13 as the urine output exceeded 2 1/24 hr (Fig. 1).The initially elevated aspartate aminotransferase (A.A.T.) of213 IU/I, and creatinine phosphokinase (C.P.K.) of 228 IU/l, returned to norml!.Urinary fibrin degradltion products (F.D.P's) were raised at 20 to 40 ~lg/ml and serum F.D.P's at 10 Ilg/ml, but the -,