Exertional rhabdomyolysis: clinical features, management, complications and prediction of acute kidney injury

Marie Vangstad; Jon Arne Kro Birkeland; Anne Kristine Gulsvik; Ragnhild Louise Ervik; Ingrid Oftebro; Fredrik Barth Brekke; Omar Ahmed Akkouh; Dag Jacobsen; Mari Asphjell Bjornaas

doi:10.1136/bmjsem-2026-003214

Exertional rhabdomyolysis: clinical features, management, complications and prediction of acute kidney injury

BMJ Open Sport Exerc Med. 2026 Mar 3;12(1):e003214. doi: 10.1136/bmjsem-2026-003214. eCollection 2026.

Authors

Marie Vangstad^{1

2}, Jon Arne Kro Birkeland³, Anne Kristine Gulsvik⁴, Ragnhild Louise Ervik^{1

5}, Ingrid Oftebro^{2

6}, Fredrik Barth Brekke^{7

8}, Omar Ahmed Akkouh⁹, Dag Jacobsen^{1

2}, Mari Asphjell Bjornaas¹

Affiliations

¹ Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.
² Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
³ Department of Nephrology, Oslo University Hospital, Oslo, Norway.
⁴ Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway.
⁵ Department of Internal Medicine, Oslo University Hospital, Oslo, Norway.
⁶ Department of Orthopedic Emergency, Oslo University Hospital, Oslo, Norway.
⁷ Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway.
⁸ Department of Medicine, Telemark Hospital, Skien, Norway.
⁹ Medical Intermediate Care Unit, Akershus University Hospital, Lørenskog, Norway.

Abstract

Objectives: To describe the clinical course and complications of exertional rhabdomyolysis, compare inpatient and outpatient management, and evaluate admission markers of acute kidney injury (AKI).

Methods: Prospective, multicentre study with consecutive inclusion of patients with rhabdomyolysis (creatine kinase (CK) ≥5000 U/L and/or myoglobin ≥1000 ng/mL) with exercise as the precipitating factor, presenting to the emergency departments of four hospitals in Oslo and Akershus, Norway (2019-2022). Management followed usual care. Primary outcome was AKI, defined by Kidney Disease: Improving Global Outcomes criteria.

Results: We included 136 patients with exertional rhabdomyolysis (median age 28 years, 55% male), mainly after strength training (106, 78%); 62 (46%) were managed as inpatients and 74 (54%) as outpatients. Management was similar in both groups, consisting of fluids, serial blood tests, with a median follow-up of 3 days. Complications were rare and no outpatients required escalation to inpatient care. Five (4%) patients developed AKI (median peak creatinine 217 µmol/L, 132-410). Other major complications (severe electrolyte disturbances and compartment syndrome) occurred only in those with AKI.All patients who developed AKI had serum creatinine above the normal reference range at admission, though a few patients with elevated creatinine did not develop AKI (95% specificity). The myoglobin-to-CK ratio (≥0.48) performed best among muscle injury biomarkers and might serve as a supportive high-risk marker (99% specificity).

Conclusion: No patient with a normal admission creatinine developed AKI in this cohort, supporting outpatient management as a safe option for otherwise healthy individuals when admission creatinine is within the reference range, provided follow-up is ensured.

Trial registration number: NCT04118608.

Keywords: Exercise; Injury; Kidney; Sport and exercise psychology; Sports & exercise medicine.

Associated data

ClinicalTrials.gov/NCT04118608