Rhabdomyolysis and Acute Renal Failure Associated with Gemfibrozil Therapy

Jose Luis Górriz, MD, Servicio de Nefrología, Hospital Dr. Peset, Avda Gaspar Aguilar, 90, E-46017 Valencia (Spain) Dear Sir, Gemfibrozil is a fibric acid derivative introduced in 1982 as a lipid-lowering drug. Adverse effects such as myopathy [1], myosi-tis [2] and rhabdomyolysis [3, 4] have been reported when it is administered in conjunction with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, and infrequent acute renal failure has also been published with this drug combination [5-7]. Preexisting mild renal impairment may increase the risk of rhabdomyolysis since the primary route of elimination of gemfibrozil is renal. We report a case of rhabdomyolysis and acute renal failure in a patient receiving gemfibrozil as the only lipidlowering agent, and in absence of any other drug or clinical condition recognized as cause of rhabdomyolysis. Material and Methods: The patient was a 70-year-old woman with a 12-year history of insulin-dependent diabetes mellitus, and in the last 7 years hypertension, currently in good control with enalapril 20 mg daily. The previous laboratory data to gemfibrozil treatment showed: plasma urea 25 mmol/l (71 mg/dl), plasma creatinine 159 mmol/l (1.8 mg/dl), hemoglobin 131 g/l, hematocrit 38.7%. The fasting lipid status showed: total plasma cholesterol 7.33 mmol/l (283 mg/dl), plasma triglyceride 3.45 mmol/l (305 mg/dl), plasma LDL-cholesterol 4.76 mmol/l (184 mg/dl), plasma HDL-cholesterol 0.95 mmol/ 1 (37 mg/dl). Due to the inefficacy of dietary treatment to control hyperlipidemia during a 3-month period, gemfibrozil was administered at a dose of 600 mg twice a day. Four days later she complained of generalized muscle weakness and tenderness in lower extremities and lumbar region, with emission of dark urine. Diclofenac 75 mg daily was added, and 48 h later the patient became oliguric. At admission, the patient appeared unwell. The temperature was 36.5°C and the blood pressure was 170/85 mm Hg. Tenderness in the lower extremities and lumbar region were detected on physical examination. Laboratory data showed: plasma urea 75.3 mmol/l (211 mg/dl), plasma creatinine 548 μmol/l (6.2 mg/dl), potassium 5.9 mmol/ 1, sodium 137 mmol/l, calcium 2.44 mmol/l (9.8 mg/dl), total proteins 7.1 g/dl, glucose 6.66 mmol/l (120 mg/dl), pH 7.27, carbon dioxide 18 mmol/l, creatine kinase (CK) 719 μmol/l (43,173 IU/1), CK-MB 2%, aspartate aminotransferase 15.2 μkat/1 (912 U/l), aldo-lase 17 IU/L (ref. < 7.6), lactate dehydroge-nase 47.2 μkat/1 (2,836