From the Guidelines
In a patient who is net positive 3105.82 mL of fluid, receiving Lactated Ringer's (LR) solution, and developing acute kidney injury (AKI), I strongly recommend immediately discontinuing the LR infusion to prevent further fluid overload, which is likely exacerbating the kidney injury, as evidenced by the KDIGO practice guideline on acute kidney injury 1. The patient's positive fluid balance is likely contributing to the AKI through renal venous congestion and increased intra-abdominal pressure, which reduces renal perfusion.
- Key considerations in managing this patient include:
- Strict intake and output monitoring with a goal of achieving neutral or negative fluid balance
- Initiating furosemide 20-40 mg IV every 8-12 hours (dose adjusted based on renal function) to promote diuresis if the patient is not oliguric, as suggested by the KDIGO guideline for the management of volume overload in AKI patients 1
- Nephrology consultation should be obtained urgently to guide further management
- Laboratory monitoring should include daily basic metabolic panel, assessment of urine output, and daily weights
- The underlying cause of the AKI must be identified and addressed, which may include stopping nephrotoxic medications, treating infections, or addressing hemodynamic issues
- It is crucial to note that the use of diuretics, such as furosemide, should be limited to patients with volume overload, as they may lead to increased mortality in other cases, as highlighted in the KDIGO guideline 1.
- If the patient remains oliguric despite these interventions, renal replacement therapy may be necessary, particularly if electrolyte abnormalities, acidosis, or uremic symptoms develop.
From the Research
Fluid Management in Acute Kidney Injury
- The patient's net positive fluid balance of 3105.82 and ongoing development of Acute Kidney Injury (AKI) despite receiving Lactated Ringer's (LR) solution suggests a complex fluid management scenario 2, 3.
- Studies have shown that excessive fluid administration can lead to fluid overload, which is associated with poor outcomes, including the development and progression of AKI 3, 4.
- A conservative strategy of fluid management, aiming for a neutral or negative balance, may be beneficial in patients with AKI, but requires careful assessment of fluid status and definition of targets to avoid hypovolemia and renal hypoperfusion 2, 5.
- The use of buffered solutions, such as LR, is preferred for fluid resuscitation in patients at risk of AKI, but the administration of fluids should be individualized and take into account patient characteristics and the nature of the acute illness 3.
- Diuretics may be used to prevent or treat fluid overload, but their efficacy in critically ill AKI patients needs to be confirmed with randomized controlled trials 6, 5.
Key Considerations
- Accurate assessment of fluid status is crucial in patients with AKI to avoid fluid overload and hypovolemia 2, 3.
- The timing and amount of fluid administration should be carefully considered to prevent AKI and other organ damage 5.
- A balanced approach to fluid management, taking into account the patient's individual needs and the potential risks and benefits of fluid therapy, is essential in patients with AKI 3, 4.