What is the treatment for rhabdomyolysis?

From the Guidelines

The treatment for rhabdomyolysis should focus on aggressive intravenous fluid resuscitation, typically with normal saline at rates of 200-300 mL/hour initially, to maintain urine output above 200-300 mL/hour, as recommended by recent guidelines 1. This approach helps flush myoglobin from the kidneys and prevent acute kidney injury.

• Monitoring and correction of electrolyte abnormalities is essential, particularly hyperkalemia, hypocalcemia, and hyperphosphatemia.
• Severe hyperkalemia may require calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium-binding resins.
• Urinary alkalinization with sodium bicarbonate (to maintain urine pH > 6.5) may be considered in severe cases to reduce myoglobin toxicity, though this remains controversial, as noted in the 2013 KDOQI commentary 1.
• Patients with severe kidney injury may require renal replacement therapy, with the decision to initiate RRT based on the broader clinical context and trends of laboratory tests, rather than single BUN and creatinine thresholds alone 1.
• The underlying cause of rhabdomyolysis must be identified and addressed, whether it's medication-related, trauma, infection, or metabolic.
• Pain management with appropriate analgesics and discontinuation of any offending medications are important supportive measures.
• Compartment syndrome, if present, requires urgent surgical fasciotomy.
• Fluid therapy continues until creatine kinase levels decrease substantially (usually below 1,000 U/L) and renal function normalizes.

From the Research

Treatment Overview

The treatment for rhabdomyolysis is primarily focused on addressing the underlying causes, managing symptoms, and preventing complications. Key aspects of treatment include:

• Aggressive intravenous fluid resuscitation (IVFR) to restore renal perfusion and increase urine flow, which is conditionally recommended to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis 2
• Early implementation of fluid therapy to prevent acute kidney injury (AKI) 3, 4
• Detection and careful treatment of electrolyte disturbances, such as hyperkalemia and hyperphosphatemia 3
• Consideration of bicarbonate or diuretics in specific cases, although their use should be carefully evaluated 3, 5

Management of Complications

Complications of rhabdomyolysis, such as hyperkalemia, compartment syndrome, and acute kidney injury, require prompt and effective treatment:

• Hyperkalemia should be managed to prevent cardiac arrhythmias and other complications 5
• Compartment syndrome should be identified and released to prevent further muscle damage and necrosis 2
• Acute kidney injury may require renal replacement therapy in severe cases 3, 5

Individualized Approach

Therapy for rhabdomyolysis should be selected individually, taking into account the underlying causes and triggers, and closely monitoring the patient's condition:

• The use of bicarbonate-containing fluids, mannitol, and loop diuretics may be considered in specific cases, although the evidence for their effectiveness is limited 2, 5
• Early and aggressive fluid resuscitation is generally agreed upon as the main intervention for preventing and treating AKI 4, 5, 6