Pink Urine Syndrome: A Combination of Insulin Resistance and Propofol

Abstract

Pink urine syndrome is mostly seen in patients treated with propofol anesthesia. The pink color is attributed to the presence of large concentrations of uric acid (and pigment), which is excreted in large amounts when propofol is given. We describe a case of propofol-induced pink urine syndrome and perform a comprehensive, evidence-based review. We discuss prior case studies already published in the literature as we speculate on the pathophysiology and how it translates to a clinically relevant entity.

Case Report: Pink Urine Syndrome Following Exposure to Propofol: A Rare, Impressive but Benign Complication

“…Pure UA dihydrate crystals are amorphous and colorless but can become pink upon absorbing pink urinary pigments ( Tan and Lai, 2012 ). PUS has been most frequently observed in patients with morbid obesity and/or insulin resistance, which may potentially involve UA metabolic disorders ( Deitel et al, 1984 ; Tucker and Perazella, 2019 ). Obesity reportedly promotes purine biosynthesis and UA production, with consequent hyperuricosuria contributing to the acidification of urine, which facilitates UA secretion into the urine ( Negri et al, 2008 ).…”

“…It is widely used as a first-line agent to sedate intubated and mechanically ventilated patients with coronavirus disease 2019 (COVID-19) and acute respiratory distress syndrome occurring during the COVID-19 pandemic ( Wei et al, 2021 ). Among anesthetic medications, propofol has most frequently been reported as a risk factor for urine discoloration ( Tucker and Perazella, 2019 ). White and green coloration of urine in patients receiving propofol treatment has been described in detail ( Tucker and Perazella, 2019 ).…”

“…Among anesthetic medications, propofol has most frequently been reported as a risk factor for urine discoloration ( Tucker and Perazella, 2019 ). White and green coloration of urine in patients receiving propofol treatment has been described in detail ( Tucker and Perazella, 2019 ). White urine is caused by the oil-in-water emulsion vehicle of propofol ( Nates et al, 1995 ); green urine, reported in three leading medical journals (New England Journal of Medicine, The Lancet and Journal of the American Medical Association), is attributed to the phenolic metabolites of propofol, which are produced by the liver and eliminated through the kidneys ( Norfleet, 1982 ; Leclercq et al, 2009 ; Boshkovska Spaseski and Spaseski, 2020 ).…”

Síndrome de la orina rosa

“…En la serie internacional se menciona la presencia de lesión renal aguda, que en nuestros casos no se ha documentado, probablemente asociada a otras situaciones distintas, como la precipitación de cristales de ácido úrico en los túbulos renales Tabla 1. Características clínicas y bioquímicas de los casos con síndrome de la orina rosa en el contexto de un paciente con hiperuricemia, situación que provoca insuficiencia renal crónica 10 .…”

“…Recientemente se publicó una revisión no exhaustiva de casos, completando 14 casos, aunque no se tienen datos uniformes (no todos tienen índice de masa corporal [IMC], niveles de ácido úrico, etc. ), se aprecian las siguientes características: 6 casos son de pacientes asiáticos, los demás dispersos en América y Europa; 11 casos son de pacientes del género masculino; el grupo etáreo más afectado es el de 61 a 70 años; 3 casos cursaron con obesidad, sin embargo, gran parte de la cohorte no tiene registrado el dato de peso/talla/ IMC, de igual forma, solo 7 casos tienen registrados los niveles de ácido úrico, y solo 2 de ellos cursan con hiperuricemia; en forma destacable, 9 casos emplearon propofol en forma previa al inicio de la manifestación de orina rosa; solo 2 casos presentaron lesión renal aguda; 3 casos estuvieron asociados a neoplasias; y 5 casos se asociaron a cirugías diversas 10 .…”