Abstract:Cerebral edema, in a variety of circumstances, may be accompanied by states of hyponatremia. The threat of brain injury from hypotonic stress-induced astrocyte demyelination is more common when vulnerable patients with hyponatremia who have end stage liver disease, traumatic brain injury, heart failure, or other conditions undergo overly rapid correction of hyponatremia. These scenarios, in the context of declining urinary output from CKD and/or AKI, may require controlled elevations of plasma tonicity vis-à-v… Show more
“… 10 , 17 , 18 , 19 In ICU patients who require RRT for AKI or ESKD but have concomitant hyponatremia, CRRT can provide controlled osmocorrection and gradual correction of hyponatremia. 1 , 2 , 5 …”
Section: Discussionmentioning
confidence: 99%
“…There are 2 approaches described in the literature to avoid overcorrection of plasma sodium levels in the setting of hyponatremia in patients with CRRT-dependent AKI or ESKD while providing adequate clearance of urea and other solutes: (1) customizing the CRRT circuit, or (2) customizing the dialysis solution 3 , 5 , 8 , 20 , 21 ( Fig 2 A and B, respectively). Figure 2 Strategies to correct hyponatremia with continuous renal replacement therapy (CRRT; modifications in double boxes) with associated pros and cons.…”
Section: Discussionmentioning
confidence: 99%
“…3 Methods proposed to overcome this issue include using lower effluent flow rates to limit solute clearance, the use of electrolyte-free water infusions (given as 5% dextrose in water) through the CRRT circuit, and the use of dialysate and replacement fluids with a reduced sodium concentration. [3][4][5][6] Although the theoretical issues involved in these methods have been discussed in detail, reports describing clinical experience using low-sodium CRRT fluids (dialysate and/or replacement fluid) are limited. 3,7,8 We report our experience with using CRRT solutions with reduced sodium concentrations (119 and 126 mEq/ L) in a series of patients who received continuous venovenous hemodiafiltration in the setting of concomitant moderate to severe hyponatremia.…”
Rationale & Objective
In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration.
Study Design
We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment.
Setting & Participants
Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours.
Results
The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome.
Limitations
Key limitations were small sample size and lack of a control group.
Conclusions
Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.
“… 10 , 17 , 18 , 19 In ICU patients who require RRT for AKI or ESKD but have concomitant hyponatremia, CRRT can provide controlled osmocorrection and gradual correction of hyponatremia. 1 , 2 , 5 …”
Section: Discussionmentioning
confidence: 99%
“…There are 2 approaches described in the literature to avoid overcorrection of plasma sodium levels in the setting of hyponatremia in patients with CRRT-dependent AKI or ESKD while providing adequate clearance of urea and other solutes: (1) customizing the CRRT circuit, or (2) customizing the dialysis solution 3 , 5 , 8 , 20 , 21 ( Fig 2 A and B, respectively). Figure 2 Strategies to correct hyponatremia with continuous renal replacement therapy (CRRT; modifications in double boxes) with associated pros and cons.…”
Section: Discussionmentioning
confidence: 99%
“…3 Methods proposed to overcome this issue include using lower effluent flow rates to limit solute clearance, the use of electrolyte-free water infusions (given as 5% dextrose in water) through the CRRT circuit, and the use of dialysate and replacement fluids with a reduced sodium concentration. [3][4][5][6] Although the theoretical issues involved in these methods have been discussed in detail, reports describing clinical experience using low-sodium CRRT fluids (dialysate and/or replacement fluid) are limited. 3,7,8 We report our experience with using CRRT solutions with reduced sodium concentrations (119 and 126 mEq/ L) in a series of patients who received continuous venovenous hemodiafiltration in the setting of concomitant moderate to severe hyponatremia.…”
Rationale & Objective
In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration.
Study Design
We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment.
Setting & Participants
Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours.
Results
The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome.
Limitations
Key limitations were small sample size and lack of a control group.
Conclusions
Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.
“…Recently Yee et al expanded on the above concepts by describing a mathematical approach to the issue of hyponatremia via sodium‐based osmotherapy while on CRRT 23 . The goal was to reduce cerebral edema in hypotonic hyponatremia.…”
Section: Discussionmentioning
confidence: 99%
“…Recently Yee et al expanded on the above concepts by describing a mathematical approach to the issue of hyponatremia via sodium-based osmotherapy while on CRRT. 23 The goal was to reduce cerebral edema in hypotonic hyponatremia. Intravenous solutions were administered in a controlled manner following a six-step protocol that utilized urea and Na kinetics.…”
Severe dysnatremias are perplexing problems in patients undergoing renal replacement therapy on a chronic or acute basis. The ability to manipulate sodium concentration in the dialysate or replacement solutions is limited. Compounding dialysate or replacement fluids to alter sodium concentration could result in errors. Rapid correction of hyponatremia or hypernatremia due to equilibrium with dialysate or replacement solutions could lead to osmotic demyelination syndrome or cerebral edema respectively. Continuous renal replacement therapy is the preferred dialysis modality in patients with severe dysnatremias. In this article, we present simple formulas to determine the rate of hypotonic or hypertonic solutions needed to mitigate rapid correction of dysnatremias. These formulas can be used readily by the clinician at bedside.
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