Myoglobinuria Treatment & Management

  • Author: Prasad Devarajan, MD; Chief Editor: Craig B Langman, MD   more...
 
Updated: Jan 4, 2010
 

Medical Care

All patients with suspected myoglobinuria or rhabdomyolysis should be admitted for intravenous (IV) hydration and management of complications. A creatine kinase (CK) level of more than 5000 U/L is considered to be an absolute indication for hospitalization and vigorous IV hydration. Initial treatment focuses on preventing myoglobin precipitation in the urine by inducing and maintaining a brisk diuresis. Immediately administer saline to patients with suspected myoglobinuria or rhabdomyolysis because early hydration is the key to ameliorate acute kidney injury. Isotonic saline boluses of 20 mL/kg should be initially administered, with repeat boluses depending on the hydration status of the patient. This should be followed by continued hydration with IV fluids given at a rate of 2-3 times maintenance.[4]

Achievement of a urine output goal of 2-3 mL/kg/h is recommended. IV hydration should be continued until the CK level is consistently less than 1000 U/L, the urine clears, and the patient is able to maintain adequate oral hydration.

Follow-up with mannitol to induce diuresis, supported by adequate IV fluids, has been advocated. Mannitol causes diuresis, which minimizes intratubular myoglobin deposition, acts as a free radical scavenger and reduces tubule cell damage, and may act as a direct renal vasodilator. However, the clinical benefit of this therapy remains unproven. In retrospective studies, volume expansion with saline alone prevented acute renal failure, and mannitol had no additional benefit.[12]

Raising the pH of the urine to 6.5 or more can be facilitated by adding sodium bicarbonate to the fluids. Alkalinization of the urine has been postulated to minimize the breakdown of myoglobin into its nephrotoxic metabolites and to reduce crystallization of uric acid, thereby decreasing damage to tubule cells. However, this modality of therapy remains somewhat controversial because large volumes of crystalloid alone may be sufficient to alkalinize the urine and because bicarbonate therapy can aggravate the hypocalcemia. No large randomized trials have demonstrated that alkalinization of urine is superior to early aggressive hydration with crystalloid in the management of rhabdomyolysis.

  • Hyperkalemia and hypocalcemia may require emergent treatment.
  • Patients with crush injuries and trauma require treatment for the soft tissue and bony injuries.
  • Patients with compartment compression due to muscle edema may require fasciotomy.
  • CK levels generally peak on day 3 and then rapidly decrease by half every 24-48 hours.
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Surgical Care

Surgical debridement may be needed if muscle damage or necrosis is extensive. Fasciotomy may be required to manage compartment compression syndrome.

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Consultations

Nephrologists may facilitate the safe initiation of diuresis to avoid dialysis. If dialysis is needed, consultation with a nephrologist is necessary.

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Activity

Activity is restricted by the extent of muscle damage. Persons who have had exertional myoglobinuria must limit their future activity and maintain adequate hydration.

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Contributor Information and Disclosures
Author

Prasad Devarajan, MD  Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of Clinical Nephrology Laboratories, Chief Executive Officer of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine

Prasad Devarajan, MD is a member of the following medical societies: American Heart Association, American Society of Nephrology, American Society of Pediatric Nephrology, National Kidney Foundation, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Watson C Arnold, MD  Director, Department of Pediatric Nephrology, Cook Children's Medical Center

Watson C Arnold, MD is a member of the following medical societies: American College of Medical Quality, American Federation for Medical Research, American Society for Nutritional Sciences, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, Sigma Xi, Southern Society for Pediatric Research, Texas Medical Association, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Laurence Finberg, MD  Clinical Professor, Department of Pediatrics, University of California at San Francisco and Stanford University

Laurence Finberg, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Frederick J Kaskel, MD, PhD  Director of the Division and Training Program in Pediatric Nephrology, Vice Chair, Department of Pediatrics, Montefiore Medical Center and Albert Einstein School of Medicine

Frederick J Kaskel, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Pediatric Society, American Physiological Society, American Society of Nephrology, American Society of Pediatric Nephrology, American Society of Transplantation, Eastern Society for Pediatric Research, Federation of American Societies for Experimental Biology, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Renal Physicians Association, Sigma Xi, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Howard Trachtman, MD  Program Director, Pediatrics Research, Schneider Children's Hospital, Department of Pediatrics, Division of Nephrology, Professor, Albert Einstein College of Medicine

Howard Trachtman, MD is a member of the following medical societies: American Society of Hypertension, American Society of Nephrology, American Society of Pediatric Nephrology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Craig B Langman, MD  The Isaac A Abt, MD, Professor of Kidney Diseases, Feinberg School of Medicine, Northwestern University; Division Head of Kidney Diseases, Children's Memorial Hospital, Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and International Society of Nephrology

Disclosure: Amgen Grant/research funds None; Altus Pharmaceuticals Grant/research funds None; Genzyme Grant/research funds None; Merck Grant/research funds None; NIH Grant/research funds None

References

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  3. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. Jul 2 2009;361(1):62-72. [Medline].

  4. Luck RP, Verbin S. Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management. Pediatr Emerg Care. Apr 2008;24(4):262-8. [Medline].

  5. Lima RS, da Silva Junior GB, Liborio AB, Daher Ede F. Acute kidney injury due to rhabdomyolysis. Saudi J Kidney Dis Transpl. Sep 2008;19(5):721-9. [Medline].

  6. Mannix R, Tan ML, Wright R, Baskin M. Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics. Nov 2006;118(5):2119-25. [Medline].

  7. Elsayed EF, Reilly RF. Rhabdomyolysis: a review, with emphasis on the pediatric population. Pediatr Nephrol. Jun 16 2009;[Medline].

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  10. Coco TJ, Klasner AE. Drug-induced rhabdomyolysis. Curr Opin Pediatr. Apr 2004;16(2):206-10. [Medline].

  11. Huerta-Alardin AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care. Apr 2005;9(2):158-69. [Medline].

  12. Brown CV, Rhee P, Chan L, et al. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?. J Trauma. Jun 2004;56(6):1191-6. [Medline].

  13. Dalakas MC. Toxic and drug-induced myopathies. J Neurol Neurosurg Psychiatry. Aug 2009;80(8):832-8. [Medline].

  14. David WS. Myoglobinuria. Neurol Clin. Feb 2000;18(1):215-43. [Medline].

  15. Fernandez WG, Hung O, Bruno GR, Galea S, Chiang WK. Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis. Am J Emerg Med. Jan 2005;23(1):1-7. [Medline].

  16. Giannoglou GD, Chatzizisis YS, Misirli G. The syndrome of rhabdomyolysis: Pathophysiology and diagnosis. Eur J Intern Med. Mar 2007;18(2):90-100. [Medline].

  17. Kilfoyle D, Hutchinson D, Potter H, George P. Recurrent myoglobinuria due to carnitine palmitoyltransferase II deficiency: clinical, biochemical, and genetic features of adult-onset cases. N Z Med J. Feb 25 2005;118(1210):U1320. [Medline].

  18. Lin AC, Lin CM, Wang TL, Leu JG. Rhabdomyolysis in 119 students after repetitive exercise. Br J Sports Med. Jan 2005;39(1):e3. [Medline].

  19. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. Jan 2004;20(1):171-92. [Medline].

  20. Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). Nov 2005;84(6):377-85. [Medline].

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Model of helical domains in myoglobin.
 
 
 
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