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«Official reprint from UpToDate ® ©2010 UpToDate ® Crush-related acute kidney injury (acute renal failure) Authors Section Editor ...»

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- We recommend the intravenous administration of an isotonic solution at a high fluid rate (Grade 1B). We suggest starting intravenous fluid replacement prior to extrication of the victim whenever possible (Grade 2B). We suggest giving isotonic saline rather than an isotonic alkaline solution (Grade 2C). Although the exact rate has not been defined by controlled studies, we suggest administering fluid at 1 L/hour initially. Since severe hyperkalemia is relatively common, intravenous solutions containing potassium, such as Ringer's lactate, are contraindicated. (See 'Prior to extrication' above.) After the victim has been removed from the rubble and urine output has been documented, we suggest switching from isotonic saline to an isotonic bicarbonate solution (Grade 2C). The optimal regimen and rate of administration are unknown. Following extrication, we administer the intravenous solution at 500 mL/hour for the first day, if there is no evidence of fluid overload and the patient can be closely monitored. We recommend close monitoring of serum bicarbonate, calcium, potassium, and serum and urine pH. We recommend discontinuing the alkaline solution if symptomatic hypocalcemia develops. (See 'Use of bicarbonate' above.)

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- If urinary flow is 20 mL/hour among victims removed from the rubble, we suggest adding mannitol to the intravenous alkaline solution (Grade 2C). We add 50 mL of 20 percent mannitol (1 to 2 g/kg per day [total, 120 g], given at a rate of 5 g/hour). If mannitol is given, the maximum rate of fluid administration is 500 mL/hour. Mannitol is contraindicated in patients with oligoanuria.

We recommend discontinuing mannitol if the desired diuresis cannot be achieved (approximately 200 to 300 mL/hour) (Grade 1B). (See 'Use of mannitol' above.)

- Once the patient can be closely monitored (such as hospital or triage setting), the administration of intravenous fluid should be adjusted to maintain the urinary output at approximately 200 to 300 mL/hour. If the urine output goal is achieved, we suggest continuing fluid therapy until the disappearance of myoglobinuria (either clinically or biochemically). This usually requires several days.

We suggest placement of a central venous pressure (CVP) catheter once the patient is in a hospital setting and closely monitoring input and all losses (urinary volume plus other losses together) of the previous day. In this setting, therapy should be based on CVP measurements, biochemical analysis, close monitoring of fluid intake and output, and body weight. (See 'Urine output goal' above.) We recommend monitoring plasma potassium and calcium several times daily until stabilized. We recommend treating hyperkalemia as discussed elsewhere. (See "Treatment and prevention of hyperkalemia".) Patients with symptomatic hypocalcemia or severe hyperkalemia may require calcium supplementation. In patients with asymptomatic hypocalcemia, we suggest not providing calcium supplementation (Grade 2C). (See "Treatment of hypocalcemia", section on 'Therapeutic approach' and "Treatment and prevention of hyperkalemia".) Dialysis is initiated for the usual indications, including volume overload, hyperkalemia, severe acidemia, and uremia. Among patients with heme pigment-induced AKI due to crush injury, we suggest intermittent hemodialysis rather than other renal replacement modalities (Grade 2C). (See "Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure): Indications, timing, and dialysis dose" and "Acute hemodialysis prescription".)

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1. Zager, RA. Studies of mechanisms and protective maneuvers in myoglobinuric acute renal injury. Lab Invest 1989; 60:619.

2. Better, OS, Stein, JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990; 322:825.

3. Zager, RA. Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int 1996;


4. Odeh, M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med 1991; 324:1417.

5. Sazama, K. Reports of 355 transfusion-associated deaths:1976 through 1985. Transfusion 1990; 30:583.

6. Sever, MS, Erek, E, Vanholder, R, Kantarci, G. Serum potassium in the crush syndrome victims of the Marmara disaster. Clin Nephrol 2003; 59:326.

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7. Shoaf, KI, Sareen, HR, Nguyen, LH, Bourque, LB. Injuries as a result of California earthquakes in the past decade. Disasters 1998; 22:218.

8. Sever, MS, Vanholder, R, Lameire, N. Management of crush-related injuries after disasters. N Engl J Med 2006; 354:1052.

9. Sheng, ZY. Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. J Trauma 1987; 27:1130.

10. Sever, MS, Erek, E, Vanholder, R, et al. The Marmara earthquake: Epidemiological analysis of the victims with nephrological problems. Kidney Int 2001; 60:1114.

11. Oda, J, Tanaka, H, Yoshioka, T, et al. Analysis of 372 patients with crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997; 42:470.

12. Hatamizadeh, P, Najafi, I, Vanholder, R, et al. Epidemiologic aspects of the Bam earthquake in Iran: the nephrologic perspective. Am J Kidney Dis 2006; 47:428.

13. Sever, MS, Erek, E, Vanholder, R, et al. Lessons learned from the Marmara disaster: Time period under the rubble. Crit Care Med 2002; 30:2443.

14. Sever, MS, Erek, E, Vanholder, R, et al. Treatment modalities and outcome of the renal victims of the Marmara earthquake. Nephron 2002; 92:64.

15. Gabow, PA, Kaehny, WD, Kelleher, SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982; 61:141.

16. Ward, MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988;


17. Vanholder, R, Sever, MS, Erek, E, Lameire, N. Rhabdomyolysis. J Am Soc Nephrol 2000;


18. Gunal, AI, Celiker, H, Dogukan, A, et al. Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes. J Am Soc Nephrol 2004;


19. Ron, D, Taitelman, U, Michaelson, M, et al. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984; 144:277.

20. Kazancioglu, R, Korular, D, Sever, MS, et al. The outcome of patients presenting with crush syndrome after the Marmara earthquake. Int J Artif Organs 2001; 24:17.

21. Reis, ND, Michaelson, M. Crush injury to the lower limbs. Treatment of the local injury. J Bone Joint Surg Am 1986; 68.414.

22. Slater, MS, Mullins, RJ. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review. J Am Coll Surg 1998; 186:693.

23. Moore, KP, Holt, SG, Patel, RP, et al. A causative role for redox cycling of myoglobin and its inhibition by alkalinization in the pathogenesis and treatment of rhabdomyolysis-induced renal failure. J Biol Chem 1998; 273:31731.

24. Zager, RA. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. Mechanistic and therapeutic implications. J Clin Invest 1992;


25. Better, OS, Rubinstein, I, Winaver, JM, Knochel, JP. Mannitol therapy revisited (1940-1997).

Kidney Int 1997; 52:886.

26. Homsi, E, Barreiro, MF, Orlando, JM, Higa, EM. Prophylaxis of acute renal failure in patients with rhabdomyolysis. Ren Fail 1997; 19:283.

27. Brown, CV, Rhee, P, Chan, L, et al. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?. J Trauma 2004; 56:1191.

28. Collins, AJ, Burzstein, S. Renal failure in disasters. Crit Care Clin 1991; 7:421.

29. Noji, EK. Acute renal failure in natural disasters. Ren Fail 1992; 14:245.

30. J Am Soc Nephrol. 2010 May;21:733-5.

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31. Vanholder, R, Sever, MS, De Smet, M, et al. Intervention of the Renal Disaster Relief Task Force in the 1999 Marmara, Turkey earthquake. Kidney Int 2001; 59:783.

32. Lameire, N, Vanholder, R, Van Biesen, W. Loop diuretics for patients with acute renal failure:

helpful or harmful?. JAMA 2002; 288:2599.

33. Mehta, RL, Pascual MT, Soroko, S, et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288:2547.

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