What is the management approach for a patient with rhabdomyolysis and decompensated cirrhosis?

Management of Rhabdomyolysis in Decompensated Cirrhosis

Aggressive fluid resuscitation with crystalloids and close monitoring of renal function should be the primary management approach for patients with rhabdomyolysis and decompensated cirrhosis.

Initial Assessment and Management

• Discontinue all nephrotoxic drugs, including NSAIDs, aminoglycosides, and other potentially harmful medications that may worsen renal function in cirrhotic patients 1, 2
• Immediately administer intravenous crystalloid fluids to restore intravascular volume and maintain adequate renal perfusion 2, 3
• Monitor for signs of volume overload, as patients with decompensated cirrhosis have impaired sodium and water handling 1, 2
• Screen for and treat any underlying infections, as they are common precipitants of both rhabdomyolysis and hepatorenal syndrome 1, 2

Specific Fluid Management

• Administer isotonic saline at a rate of approximately 200 mL/hour in the first 24-48 hours, adjusting based on clinical response 3
• Consider 20% albumin solution (1 g/kg body weight, maximum 100 g) for two consecutive days if the patient shows signs of acute kidney injury (AKI) stage >1A 1
• Target urine output of at least 100-200 mL/hour to promote clearance of myoglobin 3

Monitoring Parameters

• Closely monitor serum creatinine, blood urea nitrogen, electrolytes (particularly potassium, calcium, and phosphate), and creatine kinase levels every 6-12 hours 2, 3
• Perform frequent acid-base assessment, as patients may develop metabolic acidosis 2
• Monitor for signs of hepatic encephalopathy, which may be precipitated by AKI or electrolyte disturbances 2
• Assess for fluid overload by monitoring daily weights, intake/output, and respiratory status 1, 2

Management of Complications

Acute Kidney Injury

• If AKI develops despite fluid resuscitation, consider vasoconstrictors plus albumin therapy 1
• Terlipressin plus albumin is the first-line treatment for hepatorenal syndrome AKI (HRS-AKI), starting with terlipressin 1 mg every 4-6 hours IV or 2 mg/day by continuous infusion 1
• Increase terlipressin dose in a stepwise manner to a maximum of 12 mg/day if there is inadequate response (decrease in serum creatinine <25% from peak) after two days 1

Renal Replacement Therapy

• Consider renal replacement therapy (RRT) for patients with:
  • Severe or refractory electrolyte abnormalities (particularly hyperkalemia)
  • Refractory acidosis
  • Volume overload unresponsive to diuretics
  • Symptomatic uremia 1
• Continuous renal replacement therapy (CRRT) is preferred over intermittent hemodialysis in hemodynamically unstable patients, as it provides better cardiovascular stability 1
• Early initiation of RRT may improve survival in patients with acute liver failure and AKI 1

Electrolyte Management

• Correct hypocalcemia if symptomatic or severe 3
• Monitor and treat hyperkalemia and hyperphosphatemia 3
• Avoid excessive bicarbonate administration, which may worsen hypocalcemia and increase the risk of calcium phosphate deposition 3

Prognostic Considerations

• Assess the severity of cirrhosis using Child-Pugh or MELD scores to guide overall management decisions 2
• Consider liver transplantation evaluation in appropriate candidates with decompensated cirrhosis 2
• For patients with both rhabdomyolysis and hepatorenal syndrome not responding to medical therapy, liver transplantation may be the definitive treatment 1

Common Pitfalls and Caveats

• Avoid mannitol and bicarbonate in patients with decompensated cirrhosis and rhabdomyolysis, as evidence suggests that adequate saline expansion alone may be sufficient to prevent renal failure 3
• Be cautious with fluid administration in patients with ascites or pulmonary edema, as they are at higher risk for volume overload 1, 2
• Recognize that patients with cirrhosis may have baseline renal dysfunction, making the diagnosis of AKI more challenging 1
• Patients with cirrhosis are at higher risk for developing hepatic encephalopathy during episodes of AKI, requiring vigilant monitoring 2
• Avoid nephrotoxic contrast agents when possible, as they may worsen renal function in the setting of rhabdomyolysis and cirrhosis 1, 2