Nephrology Book

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Rhabdomyolysis

Aka: Rhabdomyolysis
  1. See Also
    1. Rhabdomyolysis Causes
    2. Statin-Induced Myopathy
    3. Acute Kidney Injury
  2. Definition
    1. Skeletal muscle breakdown
    2. Rhabdomyolysis is analogous to other multi-system failure conditions
      1. Acute Tubular Necrosis (ATN)
      2. Disseminated Intravascular Congestion (DIC)
      3. Acute Respiratory Distress Syndrome (ARDS)
  3. Pathophysiology: Pathway
    1. Muscle injury allows calcium influx
    2. Increased intracellular calcium destroys muscle fibers
    3. Release of muscle fiber contents into circulation
      1. Myoglobin
      2. Potassium
      3. Phosphate
      4. Creatine Phosphokinase
      5. Uric Acid
    4. Myoglobin overloads Haptoglobin binding capacity
    5. Myoglobin blocks renal tubules
    6. Results in Renal Failure
  4. Causes
    1. See Rhabdomyolysis Causes
    2. See Statin-Induced Myopathy
  5. Signs
    1. Muscle pain (myalgias)
    2. Muscle Weakness
    3. Localized swelling or Bruising
    4. Constitutional symptoms
      1. Fever
      2. Malaise
      3. Nausea or Vomiting
      4. Confusion, agitation, or Delirium
    5. Urinary tract symptoms
      1. Tea-colored urine
      2. Anuria
  6. Labs
    1. Urinalysis: Findings suggestive of Myoglobinuria
      1. Dipstick orthotoluidine positive for blood
      2. No Red Blood Cells seen in freshly spun sediment
      3. Differential diagnosis for positive dipstick blood and negative microscopy
        1. Intravascular Hemolysis with circulating free Hemoglobin
        2. Causes include transfusion reaction, DIC, Hemolytic Uremic Syndrome
    2. Creatine Phosphokinase increased
      1. CPK over 16,000 associated with Renal Failure
    3. Myoglobin level increased in urine or serum
      1. Results not available for days after sending sample
      2. Not helpful in acute diagnosis
  7. Complications
    1. Electrolyte disturbance
      1. Early findings
        1. Hyperkalemia
        2. Hypocalcemia
        3. Hyperphosphatemia
        4. Hyperuricemia
      2. Late findings
        1. Hypercalcemia
        2. Hypophosphatemia
    2. Acute Renal Failure (Acute Tubular Necrosis)
      1. Accounts for 5 to 15% of Acute Renal Failure cases
      2. Mechanism: Myoglobin overload, hypovolemia, acidosis
      3. Associated with Creatinine kinase over 16,000 units/L
    3. Miscellaneous complications
      1. Liver inflammation
      2. Cardiac arrhythmia or Cardiac Arrest
      3. Disseminated Intravascular Coagulation
      4. Compartment Syndrome
  8. Management: Intravenous Fluids
    1. Initial: Forced diuresis
      1. Start immediately (especially in first 6 hours)
      2. Protocol
        1. Normal Saline 1.5 Liters per hour
        2. Urine output should approach 300 ml/hour
      3. End-points
        1. No Myoglobinuria
        2. Creatine Phosphokinase (CPK) less than 1000
    2. Maintenance: Alkalinize Urine pH > 6.5
      1. Indications: Low Urine pH in Rhabdomyolysis
        1. Theory: Myoglobin less nephrotoxic in a more alkaline environment
        2. Use is controversial and is based on expert opinion, not studies
      2. Protocol
        1. Saline 0.45% (1/2 NS) with
        2. Sodium Bicarbonate 40 meq (1 to 2 ampules) and
        3. Mannitol 10 grams per liter
      3. Contraindications
        1. Persistent oliguria despite hydration listed above
        2. Hypocalcemia (provoked by Sodium Bicarbonate)
    3. Monitoring of elderly with comorbid conditions
      1. Intensive care unit admission
      2. Hourly Vital Signs including input and output
      3. Consider invasive monitoring
  9. Management: Acute Renal Failure
    1. Results from Acute Tubular Necrosis
    2. Daily Hemodialysis may be indicated
    3. Many patients show partial or complete renal recovery
  10. Precautions
    1. Aggressive hydration is critical
    2. Avoid Diuretics (may provoke Renal Failure)
    3. Do not correct Hypocalcemia unless symptomatic
      1. Anticipate Serum Calcium increase in recovery phase
      2. Calcium re-mobilized from injured muscles
  11. References
    1. Marx in Rosen (2002) Emergency Medicine 1762-70
    2. Sauret (2002) Am Fam Physician 65(5):907-12 [PubMed]

Rhabdomyolysis (C0035410)

Definition (CHV) a potentially fatal disease that destroys skeletal muscle
Definition (MSH) Necrosis or disintegration of skeletal muscle often followed by myoglobinuria.
Concepts Pathologic Function (T046)
MSH D012206
ICD9 728.88
ICD10 M62.82
SnomedCT 268106003, 156729009, 311511000009102, 240131006, 89010004
English Rhabdomyolyses, Rhabdomyolysis, RHABDOMYOLYSIS, rhabdomyolysis, rhabdomyolysis (diagnosis), Rhabdomyolysis [Disease/Finding], Necrosis of skeletal muscle, Skeletal muscle necrosis, Necrosis of skeletal muscle (finding), Rhabdomyolysis (disorder), Rhabdomyolysis (morphologic abnormality)
French RHABDOMYOLYSE, Rhabdomyolyse
Portuguese RABDOMIOLISE, Rabdomiólise
Spanish RABDOMIOLISIS, rabdomiólisis (anomalía morfológica), rabdomiólisis, Rabdomiolisis, rabdomiólisis (trastorno), Rabdomiólisis
German RHABDOMYOLYSE, Rhabdomyolyse
Swedish Rabdomyolys
Czech rabdomyolýza, rhabdomyolýza, Rabdomyolýza
Finnish Rabdomyolyysi
Russian RABDOMIOLIZ, РАБДОМИОЛИЗ
Croatian Not Translated[Rhabdomyolysis]
Polish Liza mięśni prążkowanych, Rabdomioliza
Japanese 横紋筋融解症, オウモンキンユウカイショウ
Hungarian Rhabdomyolysis
Norwegian Rabdomyolyse
Dutch rabdomyolyse, Myolyse, rabdo-, Rabdomyolyse
Italian Rabdomiolisi
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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