Kidney nontumor / medical renal

Tubulointerstitial disease

Drug and toxin related tubulointerstitial injury


Editor-in-Chief: Debra L. Zynger, M.D.
Amanda Breitbarth Borgen, M.D.
Nicole K. Andeen, M.D.

Last author update: 13 April 2022
Last staff update: 20 September 2022

Copyright: 2019-2023,, Inc.

PubMed Search: Rhabdomyolysis kidney

Amanda Breitbarth Borgen, M.D.
Nicole K. Andeen, M.D.
Page views in 2022: 1,893
Page views in 2023 to date: 1,886
Cite this page: Breitbarth Borgen A, Andeen NK. Rhabdomyolysis. website. Accessed September 30th, 2023.
Definition / general
  • Acute tubular injury with myoglobin+ tubular casts seen in setting of rhabdomyolysis
Essential features
  • Acute tubular injury with myoglobin+ tubular casts
  • Seen in setting of rhabdomyolysis; also has elevated serum creatine kinase
  • Also called pigment nephropathy
ICD coding
  • ICD-10: M62.82 - rhabdomyolysis
  • Rhabdomyolysis results from muscle injury (Crit Care 2014;18:224):
    • Traumatic: crush injury, exercise, seizure
    • Drug related: cocaine, heroin, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) inhibitors, rapamycin, oseltamivir (Transplantation 2006;82:645)
    • Toxic: clostridial toxin, snake venom
    • Malignant hyperthermia
    • Electrical current
Diagrams / tables

Images hosted on other servers:



Clinical features
  • Urinalysis: dipstick positive for heme protein, no erythrocytes, dark pigmented casts on urine microscopy
  • Elevated creatine kinase, often > 100,000 U/L
  • Elevated creatinine
  • Electrolyte abnormalities: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
  • Reference: Crit Care 2014;18:224
Prognostic factors
  • Time to diagnosis and treatment
  • Age (younger patients have better recovery)
  • Reference: Crit Care 2014;18:224
Case reports
Microscopic (histologic) description
  • Acute tubular injury: loss of brush borders, attenuation and sloughing of epithelium
  • Granular or pigmented casts in tubules
  • Interstitial edema
  • Glomeruli spared
Microscopic (histologic) images

Contributed by Mazdak Khalighi, M.D. and Nicole K. Andeen, M.D.

Acute tubular injury with pigmented, granular and focally stringy appearing casts



Immunofluorescence description
  • Negative immunofluorescence
Positive stains
  • Myoglobin immunohistochemistry highlights casts
Electron microscopy description
  • Casts have electron dense granules
Sample pathology report
  • Native kidney biopsy:
    • Myoglobin cast nephropathy
    • Comment: consistent with the clinical history of acute kidney injury and rhabdomyolysis in this patient, kidney biopsy demonstrates acute tubular injury / acute tubular necrosis with associated myoglobin positive casts, characteristic of myoglobin cast nephropathy
Differential diagnosis
  • Hemoglobinuria:
    • May have similar appearing pigmented casts
    • Casts are negative for myoglobin and positive for hemoglobin by IHC
  • Light chain cast nephropathy:
    • Has atypical "fractured" or "cracked" casts with cellular reaction
    • Strong light chain staining bias (kappa or lambda) by immunofluorescence
    • Casts are negative for myoglobin by IHC
  • Other acute tubular injury, including toxic or ischemic:
    • Also has acute tubular injury with granular debris in tubular lumen
    • Normal serum creatine kinase
    • Casts are negative for myoglobin by IHC
Board review style question #1
A patient presents with acute kidney injury and renal biopsy demonstrates acute tubular injury. Tubular casts stain with myoglobin by immunohistochemistry. What plasma enzyme will be elevated and what is the correct clinical diagnosis?

  1. Creatine kinase; rhabdomyolysis
  2. Creatinine; multiple myeloma
  3. Lactate dehydrogenase; paroxysmal nocturnal hemoglobinuria
  4. Troponin; myocardial infarction
Board review style answer #1
A. Creatine kinase; rhabdomyolysis

Comment Here

Reference: Rhabdomyolysis
Board review style question #2

A kidney biopsy shows acute tubular injury and myoglobin stain is positive in tubular casts. What is the most likely clinical history for the patient?

  1. Dehydration
  2. Multiple myeloma
  3. Rapidly progressive glomerulonephritis (RPGN)
  4. Trauma, extreme physical exercise or prolonged immobilization
Board review style answer #2
D. Trauma, extreme physical exercise or prolonged immobilization

Comment Here

Reference: Rhabdomyolysis
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