Prevention of rhabdomyolysis‐induced acute kidney injury – A DASAIM/DSIT clinical practice guideline

Abstract

Background: Rhabdomyolysis-induced acute kidney injury (AKI) is a common and serious condition. We aimed to summarise the available evidence on this topic and provide recommendations according to current standards for trustworthy guidelines. Methods: This guideline was developed using Grading of RecommendationsAssessment, Development, and Evaluation (GRADE). The following preventive interventions were assessed: (a) fluids, (b) diuretics, (c) alkalinisation, (d) antioxidants, and (e) renal replacement therapy. Exclusively patient-important outcomes were assessed. Results:We suggest using early rather than late fluid resuscitation (weak recommendation, very low quality of evidence). We suggest using crystalloids rather than colloids (weak recommendation, low quality of evidence). We suggest against routine use of loop diuretics as compared to none (weak recommendation, very low quality of evidence). We suggest against use of mannitol as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of any diuretic as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of alkalinisation with sodium bicarbonate as compared to none (weak recommendation, low quality of evidence). We suggest against the routine use of any alkalinisation as compared to none (weak recommendation, low quality of evidence). We suggest against routine use of renal replacement therapy as compared to none (weak recommendation, low quality of evidence). For the remaining PICO questions, no recommendations were issued. Conclusion:The quantity and quality of evidence supporting preventive interventions for rhabdomyolysis-induced AKI is low/very low. We were able to issue eight weak recommendations and no strong recommendations.

Rhabdomyolysis and acute kidney injury in severe COVID-19 infection

“…Contemporary guidelines offer weak evidence-based treatment recommendations to prevent rhabdomyolysis-induced AKI. 14 The main recommendation of these guidelines includes early crystalloid-based fluid resuscitation. The routine use of diuretics, alkalinisation, mannitol, antioxidants and renal replacement therapy is not recommended.…”

Role of Bicarbonates and Mannitol in Rhabdomyolysis: A Comprehensive Review

“…Recently an article published by Michelsen et al also discouraged the use of bicarbonates and mannitol while categorizing it as a weak recommendation [37].…”

“…Brown et al and Homsi et al mentioned that the use of bicarbonates and mannitol in patients with rhabdomyolysis seems unrelated or did not improve the clinical outcomes in their study [ 6 , 30 ]. Recently an article published by Michelsen et al also discouraged the use of bicarbonates and mannitol while categorizing it as a weak recommendation [ 37 ].…”

“…Some studies propose that patients benefit from sodium bicarbonate and mannitol infusions [ 7 ]. However, other recent studies suggest against their use to prevent myoglobinuric renal failure as there is little evidence other than from animal studies, retrospective observational studies, and case series to support their routine use [ 8 , 9 ].…”

Clinical practice guideline on prevention of rhabdomyolysis induced acute kidney injury: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

“…Best practice recommendations have been difficult to formulate due to incomplete understanding of the pathogenesis behind rhabdomyolysis induced AKI, lack of consensus definitions and lack of human studies. In 2019, the Danish Society of Intensive Care Medicine (DSIT) and the Danish Society of Anesthesiology and Intensive Care Medicine (DASAIM) summarized the available evidence and provided recommendations for the prevention of rhabdomyolysis‐induced AKI …”