ICU Decoded › Library › Ward Pathways › Nephrology › Acute Tubular Necrosis (incl. Rhabdomyolysis)Acute Tubular Necrosis (incl. Rhabdomyolysis)Emergency
Nephrology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Found on the floor for 18 hours; tea-coloured urine; CK 48,000 U/L; creatinine 3.4 mg/dL; K⁺ 6.2; muddy-brown casts (or ATN after sepsis/nephrotoxin)
Red flags ECG changes / K⁺ ≥6.5 Oliguria with overload Tense, painful limb Temperature ≥40 °C (heat stroke) Differential diagnosis Prerenal AKI Acute interstitial nephritis Glomerulonephritis Obstruction Haemoglobinuria (haemolysis) When to admit, call ICU or discharge Admit: CK >5000 U/L, AKI, electrolyte disturbanceICU: Hyperkalaemia with ECG change, refractory acidosis, overload, multiorgan failureDialysis: Refractory K⁺, acidosis, overload or uraemia (indication-driven)CRRT: Unstable patients: regional citrate anticoagulation, effluent 20–25 mL/kg/hKey points Early fluids (first 6 h) prevent most rhabdomyolysis AKI. Urine dipstick "blood" with no red cells on microscopy = myoglobin or haemoglobin. Most ATN recovers in 1–3 weeks; a polyuric phase follows — watch K⁺, Mg and volume. Never Miss hyperkalaemia in rhabdomyolysis Give calcium for asymptomatic hypocalcaemia Keep pushing fluids into an oliguric, overloaded patient Give nephrotoxins or unadjusted doses Common mistakes Missing hyperkalaemia Late fluids Treating calcium Nephrotoxins Disposition and follow-up HDU/ICU if unstable or needing CRRT; nephrology follow-up if not fully recovered.
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