Can liver cirrhosis and acute kidney injury (AKI) cause rhabdomyolysis?

From the Guidelines

Liver cirrhosis and acute kidney injury (AKI) can indeed contribute to the development of rhabdomyolysis, although they are not the most common direct causes. Rhabdomyolysis occurs when damaged muscle tissue releases proteins and electrolytes into the blood, potentially causing kidney damage. In liver cirrhosis, several mechanisms can lead to rhabdomyolysis, including electrolyte abnormalities (particularly hypokalemia and hypophosphatemia), alcohol-related muscle damage if alcoholic cirrhosis is present, and impaired metabolism of drugs that might be myotoxic, as suggested by the management of nephrotoxins in AKI patients 1. With acute kidney injury, the accumulation of uremic toxins can damage muscle cells, while electrolyte disturbances common in AKI (especially hyponatremia) may trigger muscle breakdown.

Key Mechanisms and Relationships

• Electrolyte abnormalities in liver cirrhosis can lead to muscle damage and rhabdomyolysis.
• Alcohol-related muscle damage in alcoholic cirrhosis is another potential cause.
• Impaired drug metabolism in liver cirrhosis can increase the risk of myotoxicity.
• Uremic toxins in AKI can damage muscle cells.
• Electrolyte disturbances in AKI, such as hyponatremia, can trigger muscle breakdown.

Management and Prevention

The management of patients with liver cirrhosis and AKI should focus on preventing rhabdomyolysis through careful monitoring of electrolyte levels, avoidance of nephrotoxic medications, and aggressive hydration, as recommended for the prevention of AKI in cirrhosis patients 1. Additionally, the evaluation of nephrotoxins as a plausible cause of AKI is crucial, and determining nephrotoxic causality involves assessing the temporal sequence between administration and the onset of injury, other possible causes, response to the removal of a drug, and in some cases the effects of restarting the drug 1.

Clinical Considerations

• The bidirectional relationship between rhabdomyolysis and AKI necessitates careful management to prevent further kidney damage.
• Early recognition and treatment of rhabdomyolysis are critical to improving outcomes in patients with liver cirrhosis and AKI.
• The use of less nephrotoxic drugs and avoidance of excessive diuretics or nonselective beta-blockade are recommended to prevent AKI in cirrhosis patients 1.

From the Research

Liver Cirrhosis and Rhabdomyolysis

• Liver cirrhosis can lead to the development of rhabdomyolysis, as shown in a study published in the Journal of Clinical Gastroenterology 2.
• The study found that rhabdomyolysis is more common in patients with liver cirrhosis, and it is often fatal, particularly in cases with acute renal failure and severe hepatic dysfunction.
• The exact mechanism of rhabdomyolysis in liver cirrhosis is not fully understood, but it is thought to be related to the underlying liver disease and its complications.

Acute Kidney Injury and Rhabdomyolysis

• Acute kidney injury (AKI) is a common complication in patients with liver cirrhosis, affecting almost 20% of these patients 3.
• AKI can lead to the development of rhabdomyolysis, as shown in a study published in the Journal of Clinical Gastroenterology 2.
• The study found that patients with liver cirrhosis and AKI have a higher mortality rate and worse outcomes compared to those without AKI.

Causes of Rhabdomyolysis in Liver Cirrhosis

• The causes of rhabdomyolysis in liver cirrhosis are often unknown, with 59.3% of cases having no identified cause 2.
• However, factors such as coexistent infection, hepatic encephalopathy, and elevated levels of serum lactate dehydrogenase and C-reactive protein can contribute to the development of rhabdomyolysis.
• Acute renal failure is also a common complication in patients with liver cirrhosis and rhabdomyolysis, with 84.0% of patients developing acute renal failure during the course of the disease 2.

Treatment and Management

• The treatment and management of rhabdomyolysis in liver cirrhosis depend on the underlying cause and mechanism of the disease.
• Volume therapy and bicarbonate therapy have been traditionally used to treat patients with rhabdomyolysis, but their effectiveness is unclear 4.
• A study published in Kidney Research and Clinical Practice found that bicarbonate therapy did not reduce the risk of AKI or improve mortality in patients with rhabdomyolysis, and high-volume fluid therapy was associated with worse renal outcomes and higher mortality 4.