Does solute-alkaline diuresis reduce morbidity or mortality in patients with crush injury?

Date First Published:

July 17, 2026

Last Updated:

July 17, 2026

Report by:

Dr Benjamin James Earle-Wright, Emergency Medicine Senior Registrar (Royal Infirmary of Edinburgh)

Search checked by:

Dr Lizzie Freeman, Anaesthetics Registrar

Three-Part Question:

In [patients with suspected crush injury] [does solute alkaline diuresis] [improve morbidity and mortality]?

Clinical Scenario:

You are the A&E registrar on night shift. There has been a major incident involving a stadium collapse and your department has received 25 patients with various crush injuries. The level 3 patients have been moved to intensive care but you are to provide ongoing care to 5 patients overnight due to bed pressures. All the patients have a CK of > 5000 and you know they all are likely to have rhabdomyolysis. You wonder if alkaline diuresis (using sodium bicarbonate infusion fluid alongside a diuretic e.g mannitol or furosemide), will improve their chances of not developing acute renal failure, requiring haemodialysis or survival?

Search Strategy:

Please see link below for comprehensive search strategy:
http://tiny.cc/CrushBestBETsLitSearch

Search Details:

A search was conducted on 2nd and 6th December 2022 and updated on 19th November 2024 to include any relevant articles published in the intervening period. The following databases were searched:
- Medline on EBSCO platform
- CINAHL on EBSCO platform
- EMBASE on Ovid platform

Limiters:
- English language
- Last 10 years
- Conference abstracts excluded

Outcome:

88 abstracts were screened and 28 full text papers reviewed:
No systematic review, clinical trial or observational study was found evaluating the use of solute alkaline diuresis vs normal fluid therapy in crush injury
One systematic review encompassing 6 studies with variable patients numbers, definitions and outcomes (rows 1-4)
Two additional case series not identified by the above systematic review are also included and summarised below.

Relevant Paper(s):

Study Title	Patient Group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Prevention of kidney injury following rhabdomyolysis: a systematic review Scharman EJ, Troutman WG January 2013 USA	Total of 461 patients across 6 different trails with varying definitions of rhabdomyolysis	Systematic Review	Development of acute renal failure	6 Studies included:	No Level 1-3 evidence identified. No direct comparison could be made between papers due to different definitions of rhabdomyolysis, urine output and AKI. Different causes of rhabdomyolysis (some trauma, some drug induced). Small numbers of patients throughout. Different background fluid regimes use
			Requirement of haemodialysis
				1 x retrospective cohort with 382 patients with CK >5000, 40% received sodium bicarbonate + mannitol. No difference in renal failure or mortality

				2 x retrospective cohort with 24 + 10 patients respectively with CK >500 - no benefit of sodium bicarbonate + mannitol over standard fluid therapy

				3 case series (2 included below - Gunal + Altintepe) with various numbers of patients (small) and treatment regimes - 2 suggesting benefit of sodium bicarbonate + mannitol, 1 suggesting no difference
Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? Brown CV et al. June 2004 USA	382 intensive care patients with CK > 5000	Retrospective cohort study	Primary: Development of acute renal failure	40% of patients received sodium bicarbonate + mannitol. No difference in retail failure (p = 0.27), dialysis (p = 0.57) or mortality (p = 0.37)	Only patients with CK > 5000 evaluated. Sodium B / mannitol given and discontinued on treating clinicians discretion.

			Secondary:
			- Need for dialysis
			- Length ITU stay
			- Mortality
Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya Altintepe et al. July 2009 Turkey	7 survivors from a 10-floor apartment collapse with crush injury	Case series	Acute Renal Failure	All 7 patients received a sodium bicarbonate / mannitol infusion (when urine output >20ml/h) alongside normal fluid resuscitation. Only 2 patients (28.6%) developed ARF requiring haemodialysis despite all having clinical rhabdomyolysis.	Small patient numbers. No control group.
Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes Gunal AI et al. July 2004 Turkey	16 survivors of the 2003 Bingol earthquake in Turkey with crush injuries	Case series	Recovery from ARF within 48 hours	All 8 patients received sodium bicarbonate / furosemide infusion alongside normal fluid resuscitation. 2 patients recovered within 48 hours, 6 died. No RRT was available for 10 days in this disaster.	Very small patient numbers No control group Very wide range of patient injuries and time under rubble (2h - 72h)
Crush syndrome: saving more lives in disasters: lessons learned from the early-response phase in Haiti Bartal C et al. April 2011 Haiti	8 survivors of the 2010 Haiti earthquake	Case series	Recovery from ARF within 48 hours	All 8 patients received sodium bicarbonate / furosemide infusion alongside normal fluid resuscitation. 2 patients recovered within 48 hours, 6 died. No RRT was available for 10 days in this disaster.	Very small patient numbers No control group Very wide range of patient injuries and time under rubble (2h - 72h)
Effect of fluid therapy on prevention of acute renal failure in Bam earthquake crush victims Sagheb MM et al. July 2009 Iran	20 survivors of the Bam earthquake with acute renal failure	Case series	Duration of acute renal failure.	7 patients who received standard fluid therapy (NaCl + Sodium bicarbonate + Mannitol (As long as urine output >20ml/h) vs 13 who received variable fluid therapy (details not recorded)	Small sample size Control group but no details about variable fluid therapy In general the variable fluid therapy group had spent more time under the rubble (6.3 vs 3.2 hours)

			Requirement of dialysis	The standard therapy group had a reduced duration of acute renal failure (7 vs 19 days) and lower requirement for haemodialysis (1 vs 6 sessions)

Author Commentary:

Overall the evidence base for the use of solute alkaline diuresis in crush syndrome is poor. There have been no studies since 2013 identified in this literature search on the topic. Research into crush injuries is inherently difficult as large numbers of crush victims are usually only seen in major incidents or disasters when there is likely to be reduced access to healthcare (4). This is compounded by poor access to healthcare data and ethical approval resulting in poor quality evidence. The one systemic review highlighted above had to draw on multiple case reports and retrospective cohort studies (5) with differing definitions and concluded that the efficacy of solute-alkaline diuresis was still not known.

The theory behind the use of sodium bicarbonate is that alkalising the urine >6.5 prevents the renal deposition of myoglobin and uric acid hence improving metabolic acidosis and reducing hyperkalaemia (1). The addition of mannitol is thought to decrease blood viscosity and dilate glomerular capillaries and hence increase filtration rate (2). However whilst the theoretical support for this therapy clearly exists

the lack of any randomised studies or even comparative studies between this treatment and standard fluid resuscitation remains. In the few case reports identified above which advocate use of solute alkaline diuresis there were no control groups. The differences in definitions between acute kidney injury, rhabdomyolysis also make it difficult to draw definitive conclusions.

A large scale prospective study is needed comparing a standard fluid regime vs fluid regime + sodium bicarbonate + mannitol with established international definitions of rhabomyolysis and AKI in order to answer the question.

Bottom Line:

The current evidence does not support the use of solute-alkaline diuresis in the treatment for crush injury, it is, at best non inferior to standard fluid therapy and carries additional risks (i.e. the overuse of mannitol in anuric patients). The combination should be avoided until better evidence if available.

References:

Scharman EJ, Troutman WG. Prevention of kidney injury following rhabdomyolysis: a systematic review
Brown CV et al.. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?
Altintepe et al.. Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya
Gunal AI et al.. Early and vigorous fluid resuscitation prevents acute renal failure in the crush victims of catastrophic earthquakes
Bartal C et al.. Crush syndrome: saving more lives in disasters: lessons learned from the early-response phase in Haiti
Sagheb MM et al.. Effect of fluid therapy on prevention of acute renal failure in Bam earthquake crush victims