1. Rhabdomyolysis Alicia M Bruno MSN CCRN ACNP
Renal Medicine Associates, Ltd.
February 24,2018

2. Disclosures
I have been an employee of RMA for 10 years, otherwise I have nothing to disclose

3. Objectives Identify a cause of Acute Kidney Injury
Define Rhabdomyolysis
Discuss Causes of Rhabdomyolysis
Discuss treatment options
Explain 1 difference in care between ESRD and AKI.

4. Case #1 CL
38 yo man with Hx of brain tumor treated with Gamma knife with hx of seizures afterwards, who has been feeling ill for the last week. He has been to the urgent care several times for SOB, fever, cough. The last visit he was Dx with influenza. Yesterday his parents went to check on him and found him unresponsive, struggling to breathe “gurgling”. It is unclear how long he was in bed in this condition. EMS brought him to the ED where he was immediately intubated.

5. Case #1 cont’d
Upon his arrival to the ED he was found with the following labs:
ABG: 7.15, CO2 50, PO2 100, HCO3 8, Sat 98%
Cr 8, BUN 100, CO2 10, Sodium 147, K 8
89/42, 101, 95.0, RR Vent 22
What other labs should we check?

6. Labs case #1 Ck 12000 UA 100 protein, moderate blood
Urine myoglobin positive

7. Case #2 RM
56 yo diabetic man with Hx of diabetic foot ulcer resistant to Vancomycin. He was started on Daptomycin 7 days ago and now is complaining of muscle aches and decreased UOP with change in color.

8. Case #2 cont’d Labs: Cr 7, BUN 89, CO2 13, K 7.4 CK 15000
Urine myoglobin positive

9. Definition of Rhabdomyolysis per Web MD “is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal failure”.
Rhabdomyolysis is the result of muscle cell death causing an increase in intracellular free ionized cytoplasmic and mitochondrial calcium.

10. Causes of Rhabdomyolysis
Non-Traumatic
Exertional
Extreme exertion (exercise)
Heat illness (environmental and malignant HTN)
Sickle cell
Seizure
Hyperkinetic state
Psychotic state, DTs, amphetamine OD
Myopathies (metabolic or mitochondrial)
Neuroleptic malignant syndrome
Non-exertional
ETOH
Drugs/toxins
Statins
Daptomycin
Colchicine
Venom CO
Infection
Viral (influenza, coxsackivirus, EB, HIV, CMV, parainfluenza, adenovirus)
Mycoplasma PNA
Bacterial
Dietary supplements
Electrolyte abnormalities
Hypokalemia

11. Causes of Rhabdomyolysis
Traumatic/Compression injury
Crush injury
Electrical injury
Prolonged immobilization
OD/coma
Inability to get up after fall
Long surgical procedures

12. Symptoms Fever Nausea/vomiting Muscle pain Weakness Malaise
Tachycardia
Altered Mental status
Dark urine
oliguria

13. Myoglobin Heme containing pigment Filtered by glomerulus
Causes kidney injury by
Tubular obstruction
Direct proximal tubule epithelial cell injury
Vasoconstriction (decreased blood to outer medulla)
Increased complexity with volume depletion

14. Diagnosis Urine Myoglobin Risk predictor
Age >50 (rises with increase in age)
Female
Serum Cr >2.2
CK >40000
Increased PO4
Bicarbonate <19

15. Treatment Hydrate CRRT/HD Treat cause Maintain adequate perfusion
Crystalloid
Sodium bicarbonate
CRRT/HD
Treat cause
Remove offending agent
Maintain adequate perfusion
Support BP/hemodynamics
Support respiratory status

16. What Happens Next DX with AKI DX with ESRD Continue dialysis
Watch for recovery
Watching for urine
Watching labs
DX with ESRD
Dialysis, dialysis, dialysis
Change the medication
Treat the problem

17. Summary Identify early Hydrate early Remove offending agent early
Maintain perfusion
Early CRRT
Watch for recovery

18. Bibliography
Up to Date