Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

For further information, see CMDT Part 22-07: Rhabdomyolysis

Key Features

  • Associated with crush injuries to muscle, immobility, drug toxicities, and hypothermia

  • Usually markedly elevated muscle enzymes and electrolyte abnormalities

  • Release of myoglobin leads to direct renal toxicity

Clinical Findings

  • Defined as a syndrome of acute necrosis of skeletal muscle associated with myoglobinuria and markedly elevated creatine kinase levels

  • Many patients are volume-contracted

    • Acute tubular necrosis is a common complication due to filtration of excess myoglobin, leading to tubular obstruction from pigmented casts and intrarenal vasoconstriction

  • Rhabdomyolysis can result from

    • Crush injuries

    • Prolonged immobility

    • Seizures

    • Substance abuse (eg, cocaine)

    • Medications (especially statins)

    • Concomitant volume depletion in these settings increases risk of rhabdomyolysis

    • Statins are an important cause of rhabdomyolysis

      • Rhabdomyolysis is increased when statins are taken with concurrent kidney or liver disease, diabetes, or hypothyroidism

      • The cytochrome P450 liver enzymes metabolize all statins except for pravastatin and rosuvastatin

      • Drugs that block the action of cytochrome P450 include protease inhibitors, erythromycin or clarithromycin, itraconazole, diltiazem, and verapamil.

      • Use of these drugs concomitantly with the statins (except pravastatin or rosuvastatin) can increase the risk of development of rhabdomyolysis

      • Rhabdomyolysis risk also increases when statins are used with niacin and fibrate-containing therapy


  • Myalgias and/or weakness may be present, but commonly asymptomatic

  • Urine may appear dark

  • Classic laboratory finding is urine dipstick testing positive for "blood" (actually myoglobin) in the absence of red cells on microscopy

    • This false-positive result is due to detection of myoglobin rather than hemoglobin

    • Urine tests for myoglobin are insensitive, however, and are positive in only 25% of patients with rhabdomyolysis

  • Other commonly encountered laboratory abnormalities include

    • Serum creatine kinase commonly >16,000 to 50,000 IU/L in clinically important rhabdomyolysis

    • Elevated serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LD) (due to release of these enzymes from skeletal muscle)

    • Hyperkalemia

    • Hyperphosphatemia

    • Hyperuricemia

    • Hypocalcemia

  • The massive acute elevations of muscle enzymes peak quickly and usually resolve within days once the inciting injury has been removed


  • Vigorous fluid resuscitation with 0.9% normal saline (> 4 L/day) is mainstay of treatment

  • Removal of offending medications

  • Use of mannitol and urine alkalinization have not been proven to change outcomes

  • Calcium

    • As patients recover, calcium can translocate from tissues to plasma

    • Early calcium administration for hypocalcemia is not recommended unless the patient is symptomatic, or the level is exceedingly low in an unconscious patient

    • Calcium repletion can cause precipitation of calcium phosphate given the frequently concurrent hyperphosphatemia

  • Myopathic complications of statins usually resolve within several weeks of discontinuing the drug

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.