What is the inpatient treatment for elevated Creatine Kinase (CK) and rhabdomyolysis?

From the Guidelines

Inpatient treatment for elevated Creatine Kinase (CK) and rhabdomyolysis should focus on aggressive IV fluid resuscitation with normal saline at 200-300 mL/hour initially, targeting urine output of 200-300 mL/hour until CK levels decrease, as this approach prioritizes reducing morbidity, mortality, and improving quality of life by preventing further kidney damage and electrolyte imbalances 1.

Key Considerations

• Monitoring should include daily CK levels, electrolytes (particularly potassium, calcium, and phosphate), renal function, and acid-base status to promptly identify and address any complications.
• Electrolyte abnormalities, such as hypophosphatemia, hypokalemia, and hypomagnesemia, which are common in patients undergoing kidney replacement therapy (KRT), should be prevented by using dialysis solutions containing potassium, phosphate, and magnesium 1.
• Urinary alkalinization with sodium bicarbonate may be considered if urine pH remains below 6.5, though this practice is somewhat controversial.
• The underlying cause of rhabdomyolysis must be identified and addressed, whether it's medication-related, trauma, excessive exercise, or other causes.

Management of Electrolyte Abnormalities

• Hypophosphatemia, hypokalemia, and hypomagnesemia can be prevented by using commercial KRT solutions enriched with phosphate, potassium, and magnesium, which are widely available and can be safely used as dialysis and replacement fluids 1.
• Hyperkalemia should be corrected promptly, using treatments such as calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium-binding resins depending on severity.

Renal Replacement Therapy

• Renal replacement therapy may be necessary for patients with severe acute kidney injury, persistent hyperkalemia, or severe acidosis, and the choice of treatment should be based on an integrated clinical judgment considering depurative needs, fluid removal needs, and hemodynamic status of the patient 1.
• The most appropriate modality of KRT should be selected based on the patient's characteristics, such as the rate of catabolism, fluid removal needs, and hemodynamic status.

From the Research

Inpatient Treatment for Elevated Creatine Kinase (CK) and Rhabdomyolysis

• The treatment for rhabdomyolysis typically involves early and aggressive fluid replacement using crystalloid solution to prevent and treat acute kidney injury (AKI) 2, 3, 4.
• Electrolyte imbalances must be treated with standard medical management, and significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest 2, 3.
• Sodium bicarbonate can be used for patients who are acidotic, and mannitol can be used for those whose urine output is not at goal 3.
• Renal replacement therapy is often implemented due to water-electrolyte or acid-base disorders 5.
• Treatment of the underlying cause of the muscle insult is the first component of rhabdomyolysis management 2.
• Intravenous fluids typically are continued until CK levels are lower than 1,000 U/L 3.
• In some cases, furosemide administration and alkalization of urine may be used in combination with fluid resuscitation to maintain an adequate urine output 4.
• The use of bicarbonates or diuretics may also be helpful, but especially in the latter case, the indications should be well evaluated, remembering to avoid hypovolemia 5.

Key Components of Treatment

• Early implementation of fluid therapy appears to be crucial 5.
• Prompt recognition and management of rhabdomyolysis is crucial to preserving renal function 3.
• CK levels should be monitored regularly and patients should be treated promptly with the adequate expansion of the extracellular volume 4.
• Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management 3.

Patient Monitoring and Care

• Patients with extremely high CK activity should be closely monitored for signs of AKI, even if renal function is initially preserved 6.
• Young age, no concurrent cocaine use, and adequate oral fluid hydration may prevent AKI in rhabdomyolysis 6.
• Urine output should be maintained at a level of at least 300 mL/hour 3.