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Myoglobinuria Treatment & Management

  • Author: Prasad Devarajan, MD, FAAP; Chief Editor: Craig B Langman, MD  more...
 
Updated: Oct 07, 2015
 

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, 17]

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.[18]

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, FAAP Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of the Nephrology Fellowship Program, Medical Director of the Kidney Stone Center, Co-Director of the Institutional Office of Pediatric Clinical Fellowships, Director of Clinical Nephrology Laboratory, CEO of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine

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

Disclosure: Received none from Coinventor on patents submitted for the use of NGAL as a biomarker of kidney injury for none.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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 Association for the Advancement of Science, Eastern Society for Pediatric Research, Renal Physicians Association, American Academy of Pediatrics, American Pediatric Society, American Physiological Society, American Society of Nephrology, American Society of Pediatric Nephrology, American Society of Transplantation, Federation of American Societies for Experimental Biology, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Received income in an amount equal to or greater than $250 from: Alexion Pharmaceuticals; Raptor Pharmaceuticals; Eli Lilly and Company; Dicerna<br/>Received grant/research funds from NIH for none; Received grant/research funds from Raptor Pharmaceuticals, Inc for none; Received grant/research funds from Alexion Pharmaceuticals, Inc. for none; Received consulting fee from DiCerna Pharmaceutical Inc. for none.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

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.

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