Pediatric Nephrology

, Volume 25, Issue 1, pp 7–18 | Cite as

Rhabdomyolysis: a review, with emphasis on the pediatric population

  • Essam F. ElsayedEmail author
  • Robert F. Reilly


Rhabdomyolysis is a common clinical syndrome and accounts for 7% of all cases of acute kidney injury (AKI) in the USA. It can result from a wide variety of disorders, such as trauma, exercise, medications and infection, but in the pediatric population, infection and inherited disorders are the most common causes of rhabdomyolysis. Approximately half of patients with rhabdomyolysis present with the triad of myalgias, weakness and dark urine. The clinical suspicion, especially in the setting of trauma or drugs, is supported by elevated creatinine kinase levels and confirmed by the measurement of myoglobin levels in serum or urine. Muscle biopsy and genetic testing should be performed if rhabdomyolysis is recurrent or metabolic myopathy is suspected. Early recognition is important to prevent AKI through the use of aggressive hydration. Prevention is important in patients with inherited forms, but novel therapies may be developed with the better understanding of the pathophysiology and genetics of rhabdomyolysis.


Acute kidney injury Genetic disorders Myoglobin Pediatric Rhabdomyolysis 


  1. 1.
    Sauret JM, Marinides G, Wang GK (2002) Rhabdomyolysis. Am Fam Phys 65:907–912Google Scholar
  2. 2.
    Zager RA (1989) Studies of mechanisms and protective maneuvers in myoglobinuric acute renal injury. Lab Invest 60:619–629PubMedGoogle Scholar
  3. 3.
    Fernandez WG, Hung O, Bruno GR, Galea S, Chiang WK (2005) Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis. Am J Emerg Med 23:1–7CrossRefPubMedGoogle Scholar
  4. 4.
    Blanco JR, Zabalza M, Salcedo J, Echeverria L, Garcia A, Vallejo M (2002) Rhabdomyolysis of infectious and noninfectious causes. South Med J 95:542–544PubMedGoogle Scholar
  5. 5.
    Antons KA, Williams CD, Baker SK, Phillips PS (2006) Clinical perspectives of statin-induced rhabdomyolysis. Am J Med 119:400–409CrossRefPubMedGoogle Scholar
  6. 6.
    Gabow PA, Kaehny WD, Kelleher SP (1982) The spectrum of rhabdomyolysis. Medicine 61:141–152CrossRefPubMedGoogle Scholar
  7. 7.
    Knochel JP (1982) Rhabdomyolysis and myoglobinuria. Annu Rev Med 33:435–443CrossRefPubMedGoogle Scholar
  8. 8.
    Billis AG, Kastanakis S, Giamarellou H, Daikos GK (1971) Acute renal failure after a meal of quail. Lancet 2:702CrossRefPubMedGoogle Scholar
  9. 9.
    Bywaters EG, Delory GE, Rimington C, Smiles J (1941) Myohaemoglobin in the urine of air raid casualties with crushing injury. Biochem J 35:1164–1168PubMedGoogle Scholar
  10. 10.
    Ward MM (1988) Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 148:1553–1557CrossRefPubMedGoogle Scholar
  11. 11.
    Mannix R, Tan ML, Wright R, Baskin M (2006) Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics 118:2119–2125CrossRefPubMedGoogle Scholar
  12. 12.
    Paletta CE, Lynch R, Knutsen AP (1993) Rhabdomyolysis and lower extremity compartment syndrome due to influenza B virus. Ann Plast Surg 30:272–273CrossRefPubMedGoogle Scholar
  13. 13.
    Gonzalez D (2005) Crush syndrome. Crit Care Med 33:S34–S41CrossRefPubMedGoogle Scholar
  14. 14.
    Zager RA (1996) Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int 49:314–326CrossRefPubMedGoogle Scholar
  15. 15.
    Vanholder R, Sever MS, Erek E, Lameire N (2000) Rhabdomyolysis. J Am Soc Nephrol 11:1553–1561PubMedGoogle Scholar
  16. 16.
    Menegaux JC (1962) Renal insufficiency in crush injuries of the muscles. Bywaters’ crush syndrome. J Chir 83:113–115Google Scholar
  17. 17.
    Celik A, Ergun O, Ozok G (2004) Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg 39:1233–1237CrossRefPubMedGoogle Scholar
  18. 18.
    Malinoski DJ, Slater MS, Mullins RJ (2004) Crush injury and rhabdomyolysis. Crit Care Clin 20:171–192CrossRefPubMedGoogle Scholar
  19. 19.
    Collins AJ (1989) Kidney dialysis treatment for victims of the Armenian earthquake. N Eng J Med 320:1291–1292Google Scholar
  20. 20.
    Bocca G, van Moorselaar JA, Feitz WF, van der Staak FH, Monnens LA (2002) Compartment syndrome, rhabdomyolysis and risk of acute renal failure as complications of the lithotomy position. J Nephrol 15:183–185PubMedGoogle Scholar
  21. 21.
    Mognol P, Vignes S, Chosidow D, Marmuse JP (2004) Rhabdomyolysis after laparoscopic bariatric surgery. Obes Surg 14:91–94CrossRefPubMedGoogle Scholar
  22. 22.
    Jolly BT, Talbot-Stern J (1995) Rhabdomyolysis secondary to keyboard overuse: occupational hazard of the computer age. Am J Emerg Med 13:644–646CrossRefPubMedGoogle Scholar
  23. 23.
    Tietjen DP, Guzzi LM (1989) Exertional rhabdomyolysis and acute renal failure following the Army Physical Fitness Test. Mil Med 154:23–25PubMedGoogle Scholar
  24. 24.
    Kuipers H (1994) Exercise-induced muscle damage. Int J Sport Med 15:132–135CrossRefGoogle Scholar
  25. 25.
    Schiff HB, MacSearraigh ET, Kallmeyer JC (1978) Myoglobinuria, rhabdomyolysis and marathon running. Q J Med 47:463–472PubMedGoogle Scholar
  26. 26.
    Kao PF, Tzen KY, Chen JY, Lin KJ, Tsai MF, Yen TC (1998) Rectus abdominis rhabdomyolysis after sit ups: unexpected detection by bone scan. Br J Sports Med 32:253–254CrossRefPubMedGoogle Scholar
  27. 27.
    Nielsen C, Mazzone P (1999) Muscle pain after exercise. Lancet 353:1062CrossRefPubMedGoogle Scholar
  28. 28.
    Sultana SR, Byrne DJ (1996) ‘Raver’s’ haematuria. J R Coll Surg Edinb 41:419–420PubMedGoogle Scholar
  29. 29.
    Spivak JL, Conti CR (1969) Post-seizure myoglobinuria. Johns Hopkins Med J 124:18–24PubMedGoogle Scholar
  30. 30.
    Hue V, Martinot A, Fourier C, Cremer R, Leteurtre S, Leclerc F (1998) Acute rhabdomyolysis in the child. Arch Pediatr 5:887–895CrossRefPubMedGoogle Scholar
  31. 31.
    Hollander AS, Olney RC, Blackett PR, Marshall BA (2003) Fatal malignant hyperthermia-like syndrome with rhabdomyolysis complicating the presentation of diabetes mellitus in adolescent males. Pediatrics 111:1447–1452CrossRefPubMedGoogle Scholar
  32. 32.
    Loke J, MacLennan DH (1998) Malignant hyperthermia and central core disease: disorders of Ca2+ release channels. Am J Med 104:470–486CrossRefPubMedGoogle Scholar
  33. 33.
    Dell KM, Schulman SL (1997) Rhabdomyolysis and acute renal failure in a child with influenza A infection. Pediatr Nephrol 11:363–365CrossRefPubMedGoogle Scholar
  34. 34.
    Salcedo J, Blanco JR (1999) Acute rhabdomyolysis by Q fever. Enferm Infec Microbiol Clin 17:250–251Google Scholar
  35. 35.
    Gamboa ET, Eastwood AB, Hays AP, Maxwell J, Penn AS (1979) Isolation of influenza virus from muscle in myoglobinuric polymyositis. Neurology 29:1323–1335PubMedGoogle Scholar
  36. 36.
    Ruff RL, Secrist D (1982) Viral studies in benign acute childhood myositis. Arch Neurol 39:261–263PubMedGoogle Scholar
  37. 37.
    Coco TJ, Klasner AE (2004) Drug-induced rhabdomyolysis. Curr Opin Pediatr 16:206–210CrossRefPubMedGoogle Scholar
  38. 38.
    Asberg A (2003) Interactions between cyclosporin and lipid-lowering drugs: implications for organ transplant recipients. Drugs 63:367–378CrossRefPubMedGoogle Scholar
  39. 39.
    Schech S, Graham D, Staffa J, Andrade SE, La Grenade L, Burgess M, Blough D, Stergachis A, Chan KA, Platt R, Shatin D (2007) Risk factors for statin-associated rhabdomyolysis. Pharmacoepidemiol Drug Saf 16:352–358CrossRefPubMedGoogle Scholar
  40. 40.
    Goldman JA, Fishman AB, Lee JE, Johnson RJ (1989) The role of cholesterol-lowering agents in drug-induced rhabdomyolysis and polymyositis. Arthritis Rheum 32:358–359CrossRefPubMedGoogle Scholar
  41. 41.
    Altman A, Szyper-Kravitz M, Shoenfeld Y (2007) Colchicine-induced rhabdomyolysis. Clin Rheumatol 26:2197–2199CrossRefPubMedGoogle Scholar
  42. 42.
    Seehusen DA, Asplund CA, Johnson DR, Horde KA (2006) Primary evaluation and management of statin therapy complications. South Med J 99:250–256CrossRefPubMedGoogle Scholar
  43. 43.
    Graham DJ, Staffa JA, Shatin D, Andrade SE, Schech SD, La Grenade L, Gurwitz JH, Chan KA, Goodman MJ, Platt R (2004) Incidence of hospitalized rhabdomyolysis in patients treated with lipid-lowering drugs. JAMA 292:2585–2590CrossRefPubMedGoogle Scholar
  44. 44.
    Deighan CJ, Wong KM, McLaughlin KJ, Harden P (2000) Rhabdomyolysis and acute renal failure resulting from alcohol and drug abuse. QJM 93:29–33CrossRefPubMedGoogle Scholar
  45. 45.
    Singhal PC, Rubin RB, Peters A, Santiago A, Neugarten J (1990) Rhabdomyolysis and acute renal failure associated with cocaine abuse. J Toxicol Clin Toxicol 28:321–330CrossRefPubMedGoogle Scholar
  46. 46.
    Melli G, Chaudhry V, Cornblath DR (2005) Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine 84:377–385CrossRefPubMedGoogle Scholar
  47. 47.
    Miller F, Friedman R, Tanenbaum J, Griffin A (1991) Disseminated intravascular coagulation and acute myoglobinuric renal failure: a consequence of the serotonergic syndrome. J Clin Psychopharmacol 11:277–279PubMedGoogle Scholar
  48. 48.
    Heled Y, Bloom MS, Wu TJ, Stephens Q, Deuster PA (2007) CK-MM and ACE genotypes and physiological prediction of the creatine kinase response to exercise. J Appl Physiol 103:504–510CrossRefPubMedGoogle Scholar
  49. 49.
    Rivera MA, Dionne FT, Wolfarth B, Chagnon M, Simoneau JA, Perusse L, Boulay MR, Gagnon J, Song TM, Keul J, Bouchard C (1997) Muscle-specific creatine kinase gene polymorphisms in elite endurance athletes and sedentary controls. Med Sci Sports Exerc 29:1444–1447PubMedGoogle Scholar
  50. 50.
    Wang Y, Korman SH, Ye J, Gargus JJ, Gutman A, Taroni F, Garavaglia B, Longo N (2001) Phenotype and genotype variation in primary carnitine deficiency. Genet Med 3:387–392PubMedGoogle Scholar
  51. 51.
    Kilfoyle D, Hutchinson D, Potter H, George P (2005) Recurrent myoglobinuria due to carnitine palmitoyltransferase II deficiency: clinical, biochemical, and genetic features of adult-onset cases. N Z Med J 118:U1320PubMedGoogle Scholar
  52. 52.
    Deschauer M, Wieser T, Zierz S (2005) Muscle carnitine palmitoyltransferase II deficiency: clinical and molecular genetic features and diagnostic aspects. Arch Neurol 62:37–41CrossRefPubMedGoogle Scholar
  53. 53.
    Longo N, di San A, Filippo C, Pasquali M (2006) Disorders of carnitine transport and the carnitine cycle. Am J Med Genet 142C:77–85CrossRefPubMedGoogle Scholar
  54. 54.
    Kim JJ, Miura R (2004) Acyl-CoA dehydrogenases and acyl-CoA oxidases. Structural basis for mechanistic similarities and differences. Eur J Biochem 271:483–493CrossRefPubMedGoogle Scholar
  55. 55.
    Smelt AH, Poorthuis BJ, Onkenhout W, Scholte HR, Andresen BS, van Duinen SG, Gregersen N, Wintzen AR (1998) Very long chain acyl-coenzyme A dehydrogenase deficiency with adult onset. Ann Neurol 43:540–544CrossRefPubMedGoogle Scholar
  56. 56.
    Voermans NC, van Engelen BG, Kluijtmans LA, Stikkelbroeck NM, Hermus AR (2006) Rhabdomyolysis caused by an inherited metabolic disease: very long-chain acyl-CoA dehydrogenase deficiency. Am J Med 119:176–179CrossRefPubMedGoogle Scholar
  57. 57.
    Lucia A, Nogales-Gadea G, Perez M, Martin MA, Andreu AL, Arenas J (2008) McArdle disease: what do neurologists need to know? Nat Clin Pract Neurol 4:568–577CrossRefPubMedGoogle Scholar
  58. 58.
    Burr ML, Roos JC, Ostor AJ (2008) Metabolic myopathies: a guide and update for clinicians. Curr Opin Rheumatol 20:639–647CrossRefPubMedGoogle Scholar
  59. 59.
    Vorgerd M, Grehl T, Jager M, Muller K, Freitag G, Patzold T, Bruns N, Fabian K, Tegenthoff M, Mortier W, Luttmann A, Zange J, Malin JP (2000) Creatine therapy in myophosphorylase deficiency (McArdle disease): a placebo-controlled crossover trial. Arch Neurol 57:956–963CrossRefPubMedGoogle Scholar
  60. 60.
    Gross M, Rotzer E, Kolle P, Mortier W, Reichmann H, Goebel HH, Lochmuller H, Pongratz D, Mahnke-Zizelman DK, Sabina RL (2002) A G468-T AMPD1 mutant allele contributes to the high incidence of myoadenylate deaminase deficiency in the Caucasian population. Neuromuscul Disord 12:558–565CrossRefPubMedGoogle Scholar
  61. 61.
    Finsterer J, Stollberger C (2008) Cardiac involvement in Becker muscular dystrophy. Can J Cardiol 24:786–792PubMedGoogle Scholar
  62. 62.
    Hoffman EP, Kunkel LM, Angelini C, Clarke A, Johnson M, Harris JB (1989) Improved diagnosis of Becker muscular dystrophy by dystrophin testing. Neurology 39:1011–1017PubMedGoogle Scholar
  63. 63.
    De Keyser J, Smitz J, Malfait R, Ebinger G (1987) Rhabdomyolysis in hypokalaemic periodic paralysis: a clue to the mechanism that terminates the paralytic attack? J Neurol 234:119–121CrossRefPubMedGoogle Scholar
  64. 64.
    Bush SP, Jansen PW (1995) Severe rattlesnake envenomation with anaphylaxis and rhabdomyolysis. Ann Emerg Med 25:845–848CrossRefPubMedGoogle Scholar
  65. 65.
    Olerud JE, Homer LD, Carroll HW (1976) Incidence of acute exertional rhabdomyolysis. Serum myoglobin and enzyme levels as indicators of muscle injury. Arch Intern Med 136:692–697CrossRefPubMedGoogle Scholar
  66. 66.
    Beetham R (2000) Biochemical investigation of suspected rhabdomyolysis. Ann Clin Biochem 37:581–587CrossRefPubMedGoogle Scholar
  67. 67.
    Watanabe T (2001) Rhabdomyolysis and acute renal failure in children. Pediatr Nephrol 16:1072–1075CrossRefPubMedGoogle Scholar
  68. 68.
    Better OS, Stein JH (1990) Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Eng J Med 322:825–829CrossRefGoogle Scholar
  69. 69.
    McKenney JM, Davidson MH, Jacobson TA, Guyton JR (2006) Final conclusions and recommendations of the National Lipid Association Statin Safety Assessment Task Force. Am J Cardiol 97:89C–94CCrossRefPubMedGoogle Scholar
  70. 70.
    Eneas JF, Schoenfeld PY, Humphreys MH (1979) The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria. Arch Int Med 139:801–805CrossRefGoogle Scholar
  71. 71.
    Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC (2004) Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma 56:1191–1196CrossRefPubMedGoogle Scholar
  72. 72.
    Sharp LS, Rozycki GS, Feliciano DV (2004) Rhabdomyolysis and secondary renal failure in critically ill surgical patients. Am J Surg 188:801–806CrossRefPubMedGoogle Scholar
  73. 73.
    Schenk MR, Beck DH, Nolte M, Kox WJ (2001) Continuous veno-venous hemofiltration for the immediate management of massive rhabdomyolysis after fulminant malignant hyperthermia in a bodybuilder. Anesthesiology 94:1139–1141CrossRefPubMedGoogle Scholar
  74. 74.
    Cox GF, Souri M, Aoyama T, Rockenmacher S, Varvogli L, Rohr F, Hashimoto T, Korson MS (1998) Reversal of severe hypertrophic cardiomyopathy and excellent neuropsychologic outcome in very-long-chain acyl-coenzyme A dehydrogenase deficiency. J Pediatr 133:247–253CrossRefPubMedGoogle Scholar
  75. 75.
    Roe CR, Yang BZ, Brunengraber H, Roe DS, Wallace M, Garritson BK (2008) Carnitine palmitoyltransferase II deficiency: successful anaplerotic diet therapy. Neurology 71:260–264CrossRefPubMedGoogle Scholar
  76. 76.
    Kiang A, Amalfitano A (2007) Progress and problems when considering gene therapy for GSD-II. Acta Myol 26:49–52PubMedGoogle Scholar

Copyright information

© IPNA 2009

Authors and Affiliations

  1. 1.Department of Internal Medicine, Section of Nephrology, VA North Texas Health Care SystemThe University of Texas Southwestern Medical Center at DallasDallasUSA
  2. 2.Dallas VA Medical Center (111G1)DallasUSA

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