Homsi E, Orlando JMC, Higa EMS, Stabile C
Prophylaxis of acute renal failure in patients with
rhabdomyolysis
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1374 1996
The therapeutic maneuver which most effectively prevents patients with
rhabdomyolysis from
developing renal failure, is not known with certainty. Volume expansion with
normal saline is
widely accepted as effective therapy. Mannitol is also effective as a volume
expanding agent.
Sodium bicarbonate may have a therapeutic effect beyond its volume expanding
abilities; it has been
proposed that an increased urinary pH obviates the nephrotoxic effects of
myoglobin, perhaps by
preventing ferrihemate precipitation. However, a prodigious amount of
bicarbonate is usually
required to alkalinize the urine sufficiently to obtain this benefit. The
risks of systemic
alkalosis are substantial, while the benefit obtained is felt by some
observers to be small or
poorly documented.
The current study by Homsi et al. examines the incremental benefit obtained
by adding mannitol and
bicarbonate to saline infusion in a group of patients with rhabdomyolysis.
This retrospective study
involved 24 patients with rhabdomyolysis of whom 9 received saline alone and
15 received saline in
addition to mannitol and bicarbonate (SMB). Although the peak CPK was higher
in the SMB group, the
serum levels of creatinine were similar in both treatment groups throughout
the observation period,
and all patients had normal renal function within 2-3 days. The authors
concluded that with
adequate saline expansion, there was little to recommend the addition of
mannitol or bicarbonate.
Comment: While this study supports a conservative approach to
rhabdomyolysis, some of the
failings of previous studies are present. The amount and rate of sodium,
chloride and bicarbonate
infusion is obscure, while there is no information concerning urine or blood
pH. Further, with no
patients demonstrating significant renal
insufficiency it may be that these patients were never at risk of the
renal dysfunction which was to be prevented.
Greg Cowell, M.D., University of Illinois at Chicago
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Am Soc Nephrol
ARF etiology :
Rhabdomyolysis