From the Guidelines
Non-traumatic rhabdomyolysis requires immediate discontinuation of potential causative agents, such as statins, red yeast rice, and certain dietary supplements, to prevent further muscle damage and reduce the risk of complications, including acute kidney injury and electrolyte abnormalities. The management of non-traumatic rhabdomyolysis involves aggressive intravenous fluid resuscitation with isotonic saline, monitoring of serum creatine kinase (CK) levels, and close monitoring of electrolytes, particularly potassium, calcium, and phosphorus 1. Patients with non-traumatic rhabdomyolysis are at risk of developing acute kidney injury, compartment syndrome, and electrolyte abnormalities, which can be life-threatening if not promptly addressed.
Causes and Risk Factors
The causes of non-traumatic rhabdomyolysis include medications, such as statins and antipsychotics, illicit drugs, infections, extreme exercise, metabolic disorders, and prolonged immobility. Certain dietary supplements, including red yeast rice, wormwood oil, licorice, creatine monohydrate, and Hydroxycut, have been associated with an increased risk of rhabdomyolysis 1.
Diagnosis and Monitoring
The diagnosis of non-traumatic rhabdomyolysis is based on clinical presentation, laboratory tests, including serum CK levels, and imaging studies. Monitoring of urine output, electrolytes, and renal function is essential to prevent complications. A repeated bio-assessment combining plasma myoglobin, plasma creatine phosphokinase (CPK), and kalaemia measurements, as well as bladder catheterization to monitor hourly urine output and urine pH, may be recommended in some cases 1.
Treatment
The treatment of non-traumatic rhabdomyolysis involves aggressive intravenous fluid resuscitation, discontinuation of potential causative agents, and monitoring of electrolytes and renal function. Alkalinization of urine with sodium bicarbonate may be considered in severe cases to prevent myoglobin precipitation in renal tubules, though this remains controversial. Dialysis may be necessary for patients with severe acute kidney injury or refractory hyperkalemia. Early recognition and prompt treatment are crucial to prevent serious complications and improve outcomes.
Prevention
Prevention of non-traumatic rhabdomyolysis involves avoiding potential causative agents, such as certain medications and dietary supplements, and prompt recognition and treatment of underlying conditions, such as infections and metabolic disorders. Patients at risk of developing non-traumatic rhabdomyolysis should be closely monitored, and healthcare providers should be aware of the potential risks and complications associated with this condition.
From the Research
Definition and Pathophysiology of Rhabdomyolysis
- Rhabdomyolysis is a clinical syndrome in which the contents of injured muscle cells leak into the circulation, resulting in electrolyte abnormalities, acidosis, clotting disorders, hypovolemia, and acute renal failure 2.
- The pathophysiology involves injury to the myocyte membrane and/or altered energy production that results in increased intracellular calcium concentrations and initiation of destructive processes 3.
- Myoglobin has been identified as the primary muscle constituent contributing to renal damage in rhabdomyolysis 3.
Causes of Rhabdomyolysis
- More than 100 conditions, both traumatic and non-traumatic, can lead to rhabdomyolysis 2.
- Common causes in hospitalized patients include prescription and over-the-counter medications, alcohol, and illicit drugs 3.
Diagnosis and Treatment of Rhabdomyolysis
- The diagnosis is confirmed by elevated creatine kinase levels, but additional testing is needed to evaluate for potential causes, electrolyte abnormalities, and AKI 3.
- Treatment is aimed at discontinuation of further skeletal muscle damage, prevention of acute renal failure, and rapid identification of potentially life-threatening complications 3.
- Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating AKI 4, 3.
- Aggressive intravenous fluid resuscitation (IVFR) has been shown to decrease the incidence of acute renal failure (ARF) and need for dialysis in patients with rhabdomyolysis 5.
Use of Bicarbonate and Mannitol in Rhabdomyolysis
- The use of bicarbonate and mannitol in the treatment of rhabdomyolysis is controversial, with some studies suggesting that they may not be beneficial 5, 6.
- A retrospective propensity score-matched cohort study found that bicarbonate therapy was associated with a higher incidence of AKI, higher rate of dialysis dependency, and higher 30-day mortality compared to non-bicarbonate therapy 6.
- The use of high-volume fluid therapy has also been shown to be associated with worse renal outcomes and higher mortality compared to low-volume fluid therapy 6.