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Crush-related acute kidney injury (acute renal failure)

Raymond Vanholder, MD, PhD
Mehmet S Sever, MD
Section Editor
Paul M Palevsky, MD
Deputy Editor
Alice M Sheridan, MD


Following rhabdomyolysis, several pathogenetic mechanisms can cause heme pigment-associated acute tubular necrosis (ATN), which results in an abrupt rise in serum creatinine, or acute kidney injury (AKI) [1-4]. (See "Definition and staging criteria of acute kidney injury in adults".)

Rhabdomyolysis may be due to either traumatic or nontraumatic muscle injury. Much of our knowledge on rhabdomyolysis-associated ATN derives from observations of traumatic rhabdomyolysis that forms the basis for development of the crush syndrome resulting from large-scale, natural or manmade disasters [5].

Treatment of both acute and chronic kidney diseases after disasters deserves special mention because it almost always requires complex technology and equipment. Crush syndrome-related AKI is the most frequent acute kidney problem after mass disasters [6].

The clinical features and prevention of AKI due to traumatic rhabdomyolysis will be reviewed here. ATN due to nontraumatic rhabdomyolysis and hemolysis and general overviews of rhabdomyolysis, hemolysis, and drug-induced myopathies are discussed in detail separately. (See "Clinical features and diagnosis of heme pigment-induced acute kidney injury" and "Clinical manifestations and diagnosis of rhabdomyolysis" and "Diagnosis of hemolytic anemia in the adult" and "Drug-induced myopathies".)


Systemic manifestations that are induced by crush injury are often referred to as crush syndrome. Crush syndrome develops in 30 to 50 percent of cases of traumatic rhabdomyolysis and is frequently seen after catastrophic earthquakes. According to some estimates, the incidence of crush syndrome ranges between 2 and 5 percent of all injured victims of catastrophic earthquakes [7-10]. All disaster victims, irrespective of whether they are mildly or severely injured, should be considered at increased risk.


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Literature review current through: Jul 2017. | This topic last updated: May 09, 2016.
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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; 49:314.
  4. Odeh M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med 1991; 324:1417.
  5. Gibney RT, Sever MS, Vanholder RC. Disaster nephrology: crush injury and beyond. Kidney Int 2014; 85:1049.
  6. Sever MS, Lameire N, Van Biesen W, Vanholder R. Disaster nephrology: a new concept for an old problem. Clin Kidney J 2015; 8:300.
  7. Bartal C, Zeller L, Miskin I, et al. Crush syndrome: saving more lives in disasters: lessons learned from the early-response phase in Haiti. Arch Intern Med 2011; 171:694.
  8. 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.
  9. Sever MS, Erek E, Vanholder R, et al. The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. Kidney Int 2001; 60:1114.
  10. 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.
  11. 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.
  12. 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.
  13. Sever MS, Erek E, Vanholder R, et al. Treatment modalities and outcome of the renal victims of the Marmara earthquake. Nephron 2002; 92:64.
  14. Malik GH, Reshi AR, Najar MS, et al. Further observations on acute renal failure following physical torture. Nephrol Dial Transplant 1995; 10:198.
  15. Stewart IJ, Faulk TI, Sosnov JA, et al. Rhabdomyolysis among critically ill combat casualties: Associations with acute kidney injury and mortality. J Trauma Acute Care Surg 2016; 80:492.
  16. Bolanos JA, Yuan CM, Little DJ, et al. Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members. Clin J Am Soc Nephrol 2015; 10:1732.
  17. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982; 61:141.
  18. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 1988; 148:1553.
  19. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol 2000; 11:1553.
  20. Sever MS, Erek E, Vanholder R, et al. Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake. Nephrol Dial Transplant 2002; 17:1942.
  21. 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; 15:1862.
  22. Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006; 354:1052.
  23. Ron D, Taitelman U, Michaelson M, et al. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984; 144:277.
  24. Kazancioğlu 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.
  25. Reis ND, Michaelson M. Crush injury to the lower limbs. Treatment of the local injury. J Bone Joint Surg Am 1986; 68:414.
  26. Slater MS, Mullins RJ. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review. J Am Coll Surg 1998; 186:693.
  27. Sever MS, Vanholder R, RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims in Mass Disasters. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant 2012; 27 Suppl 1:i1.
  28. 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.
  29. Zager RA. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. Mechanistic and therapeutic implications. J Clin Invest 1992; 90:711.
  30. Better OS, Rubinstein I, Winaver JM, Knochel JP. Mannitol therapy revisited (1940-1997). Kidney Int 1997; 52:886.
  31. Homsi E, Barreiro MF, Orlando JM, Higa EM. Prophylaxis of acute renal failure in patients with rhabdomyolysis. Ren Fail 1997; 19:283.
  32. 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.
  33. Sever MS, Erek E, Vanholder R, et al. Serum potassium in the crush syndrome victims of the Marmara disaster. Clin Nephrol 2003; 59:326.
  34. Collins AJ, Burzstein S. Renal failure in disasters. Crit Care Clin 1991; 7:421.
  35. Noji EK. Acute renal failure in natural disasters. Ren Fail 1992; 14:245.
  36. Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective? J Am Soc Nephrol 2010; 21:733.
  37. Sever MS, Erek E, Vanholder R, et al. The Marmara earthquake: admission laboratory features of patients with nephrological problems. Nephrol Dial Transplant 2002; 17:1025.
  38. Vanholder R, Borniche D, Claus S, et al. When the earth trembles in the Americas: the experience of Haiti and Chile 2010. Nephron Clin Pract 2011; 117:c184.
  39. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007; 35:64.
  40. Pinsky MR, Brophy P, Padilla J, et al. Fluid and volume monitoring. Int J Artif Organs 2008; 31:111.
  41. 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.
  42. Lameire N, Vanholder R, Van Biesen W. Loop diuretics for patients with acute renal failure: helpful or harmful? JAMA 2002; 288:2599.
  43. Mehta RL, Pascual MT, Soroko S, et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288:2547.
  44. Sever MS, Erek E, Vanholder R, et al. Renal replacement therapies in the aftermath of the catastrophic Marmara earthquake. Kidney Int 2002; 62:2264.