How to manage rhabdomyolysis in patients with cirrhosis?

Management of Rhabdomyolysis in Patients with Cirrhosis

Aggressive intravenous fluid resuscitation with crystalloid balanced solutions is the cornerstone of management for rhabdomyolysis in cirrhotic patients, with careful monitoring to prevent fluid overload and worsening of ascites. 1

Initial Assessment and Diagnosis

• Perform early evaluation of volume status, perfusion, and cardiovascular function using bedside echocardiography to guide fluid management 2
• Monitor creatine kinase (CK) levels to confirm diagnosis (>500 IU/L) and assess severity 3
• Evaluate renal function with serum creatinine and urine output monitoring, as cirrhotic patients are at high risk for acute kidney injury (AKI) 4
• Assess for compartment syndrome, which requires immediate surgical intervention regardless of other treatments 1

Fluid Management

• Administer balanced crystalloids (e.g., Ringer's lactate) as first-line fluid therapy for rhabdomyolysis in cirrhotic patients 2, 1
• Target adequate urine output (>0.5 mL/kg/hr) while carefully monitoring for signs of fluid overload 1, 5
• Avoid overtransfusion which can increase portal hypertension and risk of variceal bleeding; undertransfusion causes tissue hypoperfusion increasing risk of multiple organ failure 4
• Consider albumin supplementation (8g/L of ascites removed) if large volume paracentesis (>5L) is required for management of ascites 6

Special Considerations in Cirrhosis

• Avoid nephrotoxic drugs including aminoglycosides and NSAIDs, which can worsen renal function in cirrhotic patients 6
• Avoid angiotensin-converting enzyme inhibitors, angiotensin II antagonists, and α1-adrenergic receptor blockers due to increased risk of renal impairment 6
• Monitor serum sodium closely and manage hyponatremia according to severity:
  • Sodium 126-135 mmol/L: continue fluid therapy without water restriction 6
  • Sodium 121-125 mmol/L: consider stopping diuretics and adopt a cautious approach 6
  • Sodium <120 mmol/L: stop diuretics and consider volume expansion with colloid or saline, avoiding increasing serum sodium by >12 mmol/L per 24 hours 6

Monitoring and Supportive Care

• Monitor electrolytes frequently, particularly potassium, calcium, and phosphate, as rhabdomyolysis can cause significant electrolyte abnormalities 5
• Maintain mean arterial pressure (MAP) ≥65 mmHg to ensure adequate renal perfusion 2
• Consider norepinephrine as first-line vasopressor if needed for hypotension, with vasopressin as second-line agent 2
• Evaluate for and treat insuficiencia suprarrenal relativa (relative adrenal insufficiency), which is common in critically ill cirrhotic patients 2

Renal Replacement Therapy

• Consider renal replacement therapy (RRT) for severe or refractory electrolyte imbalances, volume overload, or symptomatic azotemia 6
• Continuous renal replacement therapy (CRRT) is preferred over hemodialysis in cirrhotic patients as it provides greater cardiovascular stability 6
• Early initiation of RRT may improve survival in critically ill patients with acute liver failure and AKI 6

Controversial Therapies

• Bicarbonate and mannitol administration are not recommended for routine use in rhabdomyolysis as they have not been shown to improve outcomes of acute renal failure or need for dialysis 1, 3
• Urine alkalinization has theoretical benefits but lacks strong clinical evidence to support its routine use 5

Liver Transplantation Considerations

• Consider liver transplantation evaluation in patients with decompensated cirrhosis and rhabdomyolysis-induced AKI 6
• Simultaneous liver-kidney transplantation may be indicated in patients with sustained AKI requiring RRT for ≥4 weeks or estimated GFR ≤35 ml/min for ≥4 weeks 6