From the Guidelines
For acute kidney injury (AKI) with metabolic acidosis, buffered crystalloids, such as lactated Ringer's or Plasma-Lyte, are generally the best fluid choice, as they can help mitigate the development of hyperchloremic metabolic acidosis associated with 0.9% normal saline 1. A typical regimen involves infusing these fluids at a rate adjusted based on the patient's size, severity of acidosis, and volume status. In less severe cases, 0.9% normal saline may be appropriate for volume resuscitation, while avoiding excessive use due to its potential to induce hyperchloremic metabolic acidosis. The use of isotonic sodium bicarbonate solution (1.26% or 150 mEq/L) may be considered in specific cases where the metabolic acidosis is severe, but its benefits over buffered crystalloids are not well established 1. Careful monitoring of electrolytes, especially potassium, calcium, and sodium, is essential during treatment, as rapid correction can cause electrolyte shifts. In patients with volume overload or heart failure, fluid administration should be more conservative, possibly requiring dialysis if acidosis is severe. Key considerations include:
- Avoiding the use of colloids, such as albumin or starches, as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI 1
- Using buffered crystalloids to reduce the risk of hyperchloremic metabolic acidosis and AKI 1
- Individualizing fluid management based on the patient's underlying condition, volume status, and electrolyte balance 1
From the Research
Fluid Management for AKI and Metabolic Acidosis
- The choice of fluid for patients with acute kidney injury (AKI) and metabolic acidosis is crucial, as it can affect the management of electrolyte and acid-base disturbances 2.
- There is no specific fluid recommended for AKI and metabolic acidosis, but the choice of fluid should be based on the patient's clinical scenario and the operational characteristics of the dialysis modality used 2.
- Hypertonic sodium chloride (NaCl) is often used in neurologically injured patients, but it can increase the risk of hyperchloremic metabolic acidosis, renal vasoconstriction, and AKI 3.
- The use of sodium acetate instead of NaCl may be beneficial in reducing the risk of AKI and hyperchloremia 3.
- Fluid and electrolyte management are essential in the management of AKI, and the choice of fluid should be individualized based on the patient's needs 4, 5, 6.
Key Considerations
- The amount of chloride exposure is a significant predictor of AKI development, and patients who receive high amounts of chloride are at increased risk of developing AKI 3.
- The choice of dialysis modality can affect the management of electrolyte and acid-base disturbances, and continuous techniques may be useful in maintaining balance and correcting these disturbances 2.
- Early determination of the underlying cause of AKI and management of electrolyte and acid-base disturbances are essential in improving patient outcomes 4, 5, 6.