Why wouldn't you use Lactated Ringer's (LR) solution in a patient with hyperkalemia?

From the Guidelines

Avoid using Lactated Ringer's (LR) solution in hyperkalemic patients, and instead opt for 0.9% Normal Saline for fluid resuscitation or maintenance in these cases. While LR contains only a small amount of potassium (4 mEq/L), it's best to completely avoid adding any additional potassium to the body when blood levels are already high, as this could potentially worsen the patient's condition 1. The use of balanced fluids, such as LR, may be limited in patients with hyperkalemia due to the presence of potassium in their composition, although some studies suggest that their use does not entail excess potassium or increased risk 1. However, as a precautionary measure, it is recommended to use potassium-free fluids like 0.9% Normal Saline to prevent further elevation of serum potassium. Additionally, the lactate in LR can be converted to bicarbonate, which may cause a slight intracellular shift of potassium, temporarily masking the severity of hyperkalemia without actually treating the underlying problem. Key considerations for fluid choice in hyperkalemic patients include:

• Avoiding fluids with potassium
• Minimizing the risk of worsening hyperkalemia
• Selecting fluids that do not affect acid-base balance in a way that could mask the severity of hyperkalemia
• Prioritizing the use of potassium-free fluids like 0.9% Normal Saline for fluid resuscitation or maintenance.

From the FDA Drug Label

Potassium-containing solutions, including Lactated Ringer’s and 5% Dextrose Injection, USP may increase the risk of hyperkalemia Patients at increased risk of developing hyperkalemia include those: • With conditions predisposing to hyperkalemia and/or associated with increased sensitivity to potassium, such as patients with severe renal impairment, acute dehydration, or extensive tissue injury or burns, certain cardiac disorders such as congestive heart failure • Treated concurrently or recently with agents or products that cause or increase the risk of hyperkalemia Avoid use of Lactated Ringer’s and 5% Dextrose Injection, USP in patients with, or at risk for, hyperkalemia. If use cannot be avoided, monitor serum potassium concentrations

You wouldn't use Lactated Ringer's (LR) solution in a patient with hyperkalemia because it contains potassium and may increase the risk of worsening hyperkalemia. Patients with hyperkalemia should avoid LR solution, and if use cannot be avoided, serum potassium concentrations should be closely monitored 2.

From the Research

Hyperkalemia and Lactated Ringer's Solution

• Lactated Ringer's (LR) solution contains potassium, which may be a concern in patients with hyperkalemia 3, 4.
• However, studies have shown that LR use is not independently associated with the development of hyperkalemia in patients with reduced kidney function 3.
• In fact, one study found that LR was associated with less hyperkalemia and acidosis compared to normal saline in patients undergoing kidney transplantation 4.
• The management of hyperkalemia in acutely ill patients involves careful consideration of the potential side effects of therapies, including potassium-lowering drugs and renal replacement therapy 5.

Considerations for Fluid Choice

• The choice of fluid in patients with septic shock may depend on various factors, including the risk of hyperkalemia and acidosis 6.
• A study comparing LR and normal saline in patients with septic shock found that LR was associated with lower incidences of hyperlactacidemia and hyperchloremia, but no significant difference in hyperkalemia 6.
• Another study found that normal saline and LR had a similar effect on quality of recovery in stable emergency department patients, with no significant difference in health care use or medication compliance 7.

Key Findings

• LR solution contains potassium, but its use is not independently associated with the development of hyperkalemia in patients with reduced kidney function 3.
• LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation, with less hyperkalemia and acidosis compared to normal saline 4.
• The management of hyperkalemia in acutely ill patients requires careful consideration of the potential side effects of therapies 5.