Table 3.

Case studies of rhabdomyolysis in individuals ingesting creatine

Age and sex	Training status	Creatine supplementation	Clinical manifestations of rhabdomyolysis	Treatment	Potential mitigating factors	Resolution	References
24 M	“Avid bodybuilder”	25 g/day for 1 year	Peak CK > 800,000 IU, severe pain anterior thigh swelling, proteinuria, hematuria, quadriceps compartment syndrome, increased compartment pressure	Emergency tri-compartment fasciotomies, aggressive hydration, physical therapy	8 days no exercise after muscle injury followed by 3 h lower-body resistance training	Quadriceps strength 60% of pre-rhabdomyolysis level at 6 mo post	[144]
33 M	Unknown	Unknown dose/duration use reported by wife	Peak CK 765,910 IU, pain, swelling, myoglobinuria, metabolic acidosis, acute renal insufficiency, increased thigh compartment pressure, thigh compartment syndrome	Hydration; alkalinization, hemodialysis, fasciotomies, resuscitation for cardiac arrest	Post-exercise (collapsed at finish line of 2-mile run, army physical fitness test), obesity, recent rapid weight loss (17 lbs in 2 wk), “natural” diuretics, dehydration, ephedrine, African American	Fatal (multi-system failure)	[23]
27 M	Unknown	5–20 g/day; unknown duration	Peak CK 83,634 IU, myoglobin 30,000 mg/dl	Hydration, alkalinization of urine, hyperbaric oxygen therapy	2 days of “extreme” exercise, ephedrine	Full function	[145]
27 M	Unknown		Peak CK 114,900, myoglobin 20,000 mg/dl, dark urine, oliguria, myalgia, thigh tenderness, increased compartment pressure	Hydration, alkalinization of urine, loop diuretics, continuous venovenous hemofiltration (for respiratory failure), thigh fasciotomy, hyperbaric oxygen therapy	2 days of “extreme” exercise, ephedrine	Full function
28 M	Unknown		Peak CK > 200,000 IU, myoglobin 23,000 mg/dl, severe pain, dark urine, increased thigh compartment pressures	Hydration, alkalinization of urine, mannitol, loop diuretics, intermittent hemodialysis, thigh fasciotomies	2 days of “extreme” exercise with dehydration, ephedrine	Full function
21 M	College football player; avid weightlifter	10 g/day for 6 wk	Peak CK 194,000 IU, Peak LDH 15,840 IU, myoglobinuria, severe pain, acute renal failure	IV fluids, IV mannitol, sodium bicarbonate, and furosemide, metoprolol, hydralazine	Hit a tree (crush injury) prior to arthroscopic knee surgery, surgical tourniquet for 100 min, immobilization/positional post-surgical rhabdomyolysis although uncommon, does occur especially in large individuals (pt was 100 kg), hypertension (156/80 mmHg), 15 mg IV ketorolac (NSAID)	Full function	[146]

CK creatine kinase, d day, IV intravenous, LDH lactate dehydrogenase, M male, mo month, NSAID non-steroidal anti-inflammatory drug, pt patient, wk week