Hepatitis, rhabdomyolysis and multi-organ failure resulting from statin use

This paper was published in the British Medical Journal Case Reports 2009;2009. pii: bcr07.2008.0412

Study title and authors:
Hepatitis, rhabdomyolysis and multi-organ failure resulting from statin use.

Rajaram M.
St Helens and Knowsley Hospitals NHS Trust, Medicine-Gastro, Whiston Hospital, Warrington Prescot, L35 5DR, UK.

This paper can be accessed at: http://www.ncbi.nlm.nih.gov/pubmed/21686823

This paper reports the case of of a woman who developed hepatitis, rhabdomyolysis and multi-organ failure resulting from the use of statins.

(i) A 77-year-old female patient was admitted to hospital with malaise, anorexia and generally feeling unwell for a week.
(ii) She was taking atorvastatin 80 mg daily.
(iii) The dose of atorvastatin was increased from 40 mg to 80 mg daily approximately six months before admission.
(iv) Examination revealed she was jaundiced.
(v) Laboratory tests revealed the following abnormalities (normal levels in brackets):
Creatine kinase: 523 iu/l (25–200)
Lactate dehydrogenase: 1241 iu/l (240–525)
Total bilirubin: 284 μmol/l (2–22)
Alanine transaminase: 2314 iu/l (11–55)
γ glutamyl transferase: 132 iu/l (5–50)
Aspartate transaminase: 1269 iu/l (12–42)
Alkaline phosphatase: 438 iu/l (40–125)
Urea: 15.9 mmol/l (3.6–7.3)
Creatinine: 290μmol/l (45–110)
(vi) A diagnosis of hepatitis related to statin use with accompanying kidney failure was made.
(vii) The statin was stopped and her liver biochemistry improved.
(viii) However on the fourth day after admission, her kidney function deteriorated.
(ix) Examination revealed excess fluid around the lungs and abdominal areas.
(x) The patient was transferred to the intensive care unit and required haemofiltration. (Hemofiltration is a kidney replacement therapy similar to hemodialysis).
(xi) Despite improvement in her kidney function, the creatine kinase levels continued to rise and peaked at 107178 iu/l.
(xii) Two weeks after admission to the hospital, the patient died of multi-organ failure.

Rajaram concludes: "The cause of hepatitis, rhabdomyolysis, and acute renal failure in this patient was the increase in dose of atorvastatin and subsequent elevation of serum atorvastatin concentration. We suggest that the elevation of atorvastatin concentrations resulted in skeletal muscle damage and rhabdomyolysis, as indicated by the elevation of creatine kinase and subsequent deposition of myoglobin in the kidneys, causing acute renal failure as indicated by the elevation of urea and creatinine".