What is the timing of peak levels of different muscle enzymes in rhabdomyolysis, including Creatine Kinase (CK)?

From the Guidelines

In rhabdomyolysis, the timing of different muscle enzyme peaks is crucial for diagnosis and management, with Creatine kinase (CK) peaking at 24-72 hours, Myoglobin peaking within 8-12 hours, and other enzymes like Lactate dehydrogenase (LDH), Aspartate aminotransferase (AST), and Alanine aminotransferase (ALT) having different peak times. The peak times of these enzymes are as follows:

• Creatine kinase (CK) rises within 2-12 hours of muscle damage, peaks at 24-72 hours, and typically normalizes within 5-7 days if no ongoing injury occurs 1
• Myoglobin appears in serum very rapidly, within 1-3 hours of muscle injury, peaks within 8-12 hours, and clears quickly with a half-life of only 2-3 hours, often returning to normal within 24-36 hours 1
• Lactate dehydrogenase (LDH) rises within 12 hours, peaks at 2-3 days, and can remain elevated for up to 14 days
• Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) typically rise within 24-48 hours and may remain elevated for 7-10 days Understanding these timing differences is clinically important because myoglobin's rapid clearance means it may be missed if testing is delayed, while CK remains the most reliable marker for diagnosis and monitoring due to its longer elevation 1. The sequential pattern of enzyme elevation and clearance can help determine the timing of muscle injury and guide appropriate management of rhabdomyolysis. Some key points to consider when interpreting these enzyme levels include:
• The optimal time point to collect blood samples after exercise, as CK does not necessarily peak within minutes post-exercise but rather between 24 and 120 hours depending on the exercise modality 1
• Confounding factors such as ethnicity, body composition, or exercising with different individual intensities can lead to highly individual kinetics and time points of peak CK levels 1
• The relationship between muscle mass and CK activity, as well as the impact of ethnicity on CK levels 1

From the Research

Timing of Different Muscle Enzyme Peak in Rhabdomyolysis

• The peak timing of different muscle enzymes in rhabdomyolysis can vary, but some studies provide insight into the patterns of creatine kinase (CK) and myoglobin elevation.
• According to a study published in the European journal of anaesthesiology 2, creatine kinase peaked between the day of admission and day 3 in 91% of cases, suggesting that CK levels may rise rapidly after the onset of rhabdomyolysis.
• The same study found that a peak creatine kinase of at least 5000 U/L is 55% specific and 83% sensitive for the prediction of acute kidney injury (AKI) requiring renal replacement therapy, indicating that high CK levels may be associated with a higher risk of AKI.
• Another study published in the European journal of emergency medicine 3 found that myoglobin concentration was a better predictor of AKI than CK activity, and that the myoglobin/CK ratio may be useful for assessing the likelihood of developing AKI.
• The timing of myoglobin peak is not explicitly stated in the provided studies, but it is known to be released into the bloodstream shortly after muscle injury, often preceding the peak of CK 4, 5.
• Overall, the timing of different muscle enzyme peaks in rhabdomyolysis can vary, but CK and myoglobin levels are important markers for diagnosis and prognosis, and their peaks may occur within the first few days after the onset of symptoms.