What are the discharge instructions for a patient with rhabdomyolysis?

Discharge Instructions for Rhabdomyolysis Patients

Patients with rhabdomyolysis require comprehensive discharge planning that includes close monitoring of kidney function, medication reconciliation with discontinuation of causative agents, hydration maintenance, activity modification, and scheduled nephrology follow-up within 3-7 days.

Immediate Post-Discharge Monitoring

Kidney Function Assessment

• Schedule laboratory evaluation within 3-7 days after discharge to assess kidney recovery, including creatinine, BUN, and electrolyte panels 1
• Measure and document kidney function at this initial follow-up visit, as patients recovering from acute kidney injury remain at risk for chronic kidney disease progression 1
• Continue weekly monitoring of creatinine values if kidney function has not fully normalized 1
• For patients discharged on dialysis, perform weekly assessment of pre-dialysis serum creatinine and regular evaluation of residual kidney function using 24-hour urine collections to measure volume, creatinine clearance, and urea clearance 1

Nephrology Follow-Up

• Arrange continued follow-up with a nephrologist, particularly for patients who had more severe kidney injury, pre-existing chronic kidney disease, diabetes, or proteinuria 1
• Patients with severe or persistent acute kidney disease require more frequent surveillance than those with lower risk 1

Medication Management

Discontinue Causative Agents

• Immediately discontinue all medications and supplements that may have contributed to rhabdomyolysis, including statins, creatine monohydrate, red yeast rice (containing lovastatin), wormwood oil, licorice, and Hydroxycut 2, 3
• For patients requiring continued lipid management after statin discontinuation, consider alternative therapies such as ezetimibe, PCSK9 inhibitors, or bempedoic acid 3
• If statins must be reintroduced in the future, use hydrophilic statins (fluvastatin, pravastatin) as they have fewer metabolic interactions 3

Medication Reconciliation and Adjustment

• Adjust all renally excreted medications based on current kidney function 1
• Avoid or withdraw nephrotoxic medications to prevent re-injury 1
• Withdraw drugs with active metabolites that may accumulate with impaired kidney function 1
• Perform comprehensive medication reconciliation to ensure all adjustments are documented 1

Hydration and Activity Instructions

Fluid Intake

• Maintain adequate oral hydration to support continued myoglobin clearance and prevent dehydration 2
• Monitor for signs of dehydration including decreased urine output, dark urine, dizziness, or dry mucous membranes 4

Activity Modification

• Cease the specific physical activity that triggered the rhabdomyolysis episode 2
• Return to normal activities in a graded fashion, avoiding sudden increases in exercise intensity or duration 5
• Properly calibrate training and conditioning sessions, especially during transition periods such as returning after injury 3
• Avoid novel overexertion or unaccustomed exercise volume/intensity that can precipitate recurrent episodes 3

Warning Signs Requiring Immediate Medical Attention

Symptoms to Monitor

• Seek immediate care for muscle pain, weakness, or swelling, particularly if accompanied by dark or tea-colored urine 4, 6
• Watch for decreased urine output (less than normal volume or frequency) 2, 6
• Monitor for severe fatigue, muscle stiffness, or cramping that worsens or does not improve 3
• Be alert for signs of compartment syndrome including severe pain, tension in limbs, numbness, tingling, or weakness 2, 3

Electrolyte-Related Symptoms

• Report palpitations, irregular heartbeat, or chest discomfort, as hyperkalemia can cause life-threatening cardiac arrhythmias 2, 3
• Seek care for confusion, severe weakness, or altered mental status 3

Special Considerations for Dialysis-Dependent Patients

Dialysis Management

• If discharged while still requiring dialysis, inform the chronic dialysis facility that a personalized approach maximizing renal recovery should be utilized 1
• Avoid excessive fluid removal and hypotension during dialysis sessions, as these can cause re-injury to the kidney and reduce likelihood of recovery 1
• Careful consideration should be given to vascular access site, avoiding subclavian veins and the internal jugular vein on the side of a potential future arteriovenous fistula 1
• Dialysis may be discontinued when urine output recovers adequately (>100 mL/day) 7

Risk-Based Surveillance Intensity

High-Risk Patients Requiring Closer Follow-Up

• Patients with more severe or persistent acute kidney disease require earlier and more frequent surveillance 1
• Those with premorbid conditions increasing risk of chronic kidney disease progression (pre-existing CKD, diabetes, proteinuria) need intensified monitoring 1
• Patients with recurrent disease or non-recovery (congestive heart failure, cirrhosis, malignancy with or without chemotherapy) benefit from more aggressive follow-up 1

Genetic and Metabolic Considerations

• For patients with recurrent rhabdomyolysis, history of exercise intolerance, or family history of neuromuscular disorders, discuss need for genetic and metabolic testing with your physician 3
• Consider testing for SLCO1B1 gene mutations if statin-induced rhabdomyolysis occurred, as genetic factors can increase risk 3

Common Pitfalls to Avoid

• Delaying follow-up laboratory assessment beyond 7 days can miss early signs of kidney function deterioration 1
• Resuming causative medications or supplements too early increases risk of recurrent episodes 2, 3
• Returning to intense physical activity without proper gradual conditioning can trigger repeat rhabdomyolysis 3, 5
• Inadequate hydration during recovery phase may compromise kidney function restoration 2
• Missing signs of compartment syndrome, particularly pain and tension in affected limbs, can lead to irreversible damage 2, 3