Management of earthquake-related acute renal injury.

This frontier will highlight the principles of diagnosis and management of earthquake crush syndrome and related acute kidney injury (AKI) based on our two recently published highly accessed collective review articles. Continuous prolonged pressure of the rubble on injured muscles following earthquakes may cause crush injuries. When the patient is extricated and the compressed muscles are relieved, an ischemia-reperfusion injury, with systematic serious metabolic disturbances, occurs. This includes hyperkalemia, rhabdomyolysis, and AKI. AKI is caused by three mechanisms. Prerenal factors include: (1) Hypovolemia due to bleeding; (2) Dehydration due to lack of water; (3) Ischaemia-reperfusion injury; and (4) Cardiac depression caused by released toxins. Renal factors include the nephrotoxic effects of the uric acid and bilirubin, tubular casts obstructing the tubules, or the direct deposition of phosphorus and calcium inside the kidneys. Pelvic fractures may cause urethral rupture with postrenal obstruction. The management principles of crush syndrome and AKI include: (1) Proper fluid therapy to maintain adequate urine output; (2) Preventing and treating hyperkalemia; and (3) Renal replacement therapy when indicated in cases of severe hyperkalemia, severe acidemia, volume overload, or severe uremia. Recognizing these conditions and treating them timely and properly will save many patients.