From the Guidelines
Hypertonic lactate solution should be avoided in acute stroke patients with impaired renal function due to potential nephrotoxicity concerns. The primary concern is that lactate metabolism, which primarily occurs in the liver, may be affected by impaired renal function, leading to potential acid-base balance regulation and electrolyte excretion issues 1.
Key Considerations
- For patients with moderate to severe renal impairment (eGFR <45 ml/min/1.73m²), alternative isotonic solutions like normal saline or balanced crystalloids (such as Plasma-Lyte) may be safer options 1.
- If hypertonic therapy is specifically needed to reduce cerebral edema, mannitol or hypertonic saline might be preferred alternatives with appropriate renal dose adjustments and monitoring 1.
- Close monitoring of renal function, serum lactate, and electrolytes is crucial when administering any fluid therapy in patients with impaired renal function 1.
Evidence Summary
The American Heart Association/American Stroke Association guidelines for the early management of patients with acute ischemic stroke recommend maintaining euvolemia and avoiding hypovolemia or hypervolemia, as both can exacerbate ischemic brain injury 1. While the guidelines do not specifically address hypertonic lactate solutions, they emphasize the importance of careful fluid management in patients with acute ischemic stroke, particularly those with impaired renal function.
Clinical Implications
In clinical practice, it is essential to weigh the potential benefits of hypertonic lactate solutions against the risks of nephrotoxicity in acute stroke patients with impaired renal function. Given the lack of specific guidance on hypertonic lactate solutions in the context of acute stroke and renal impairment, caution and careful monitoring are advised 1. Alternative fluid therapies, such as isotonic solutions, may be preferred in these patients to minimize the risk of nephrotoxicity and ensure optimal outcomes.
From the Research
Hypertonic Lactate Solution in Stroke and Nephrotoxicity
- The use of hypertonic lactate solution in acute stroke patients with impaired renal function has raised concerns about nephrotoxicity 2.
- However, a study on a porcine model of hemorrhagic shock found that hypertonic sodium lactate solution did not produce renal dysfunction, despite causing significant increases in serum sodium and osmolality 2.
- Another study compared the effectiveness of hypertonic lactate (HL) with hypertonic saline (HS) in treating intracranial hypertension in patients with acute brain injury, and found that HL did not cause hyperchloremia and resulted in a more favorable systemic chloride balance than HS 3.
- There is limited research directly addressing the safety of hypertonic lactate solution in acute stroke patients with impaired renal function, but available studies suggest that it may be a viable alternative to hypertonic saline 3, 2.
- A study on the role of hypertonic saline for the management of intracranial hypertension after stroke and traumatic brain injury noted that hypertonic saline has a high risk of injury with inappropriate administration and is considered a "high-alert" drug, highlighting the need for careful consideration of safety issues surrounding its dispensing and administration 4.
- The comparison of mannitol and hypertonic saline in reducing intracranial pressure in acute liver failure found that hypertonic saline was significantly better in preventing rebound cerebral edema with lower renal dysfunction 5.
Key Findings
- Hypertonic lactate solution may be a safe and effective alternative to hypertonic saline in treating intracranial hypertension in patients with acute brain injury 3.
- The use of hypertonic lactate solution does not appear to cause significant renal dysfunction, despite causing increases in serum sodium and osmolality 2.
- Careful consideration of safety issues surrounding the dispensing and administration of hypertonic solutions is necessary to minimize the risk of injury 4.