Can fluids be administered to a patient with impaired renal function, specifically an estimated Glomerular Filtration Rate (eGFR) of 38?

From the Guidelines

Yes, fluids can be administered to a patient with an eGFR of 38, but careful monitoring is required. For a patient with this moderate kidney impairment (Stage 3b CKD), isotonic fluids like normal saline (0.9% NaCl) or lactated Ringer's solution can be administered when clinically indicated for conditions such as dehydration, hypotension, or during perioperative management 1. The rate and volume should be tailored to the patient's clinical status, with typical initial rates of 100-125 mL/hour for maintenance or 250-500 mL boluses for volume resuscitation.

Key Considerations

• During fluid administration, closely monitor vital signs, urine output, daily weights, and electrolytes, particularly potassium, sodium, and bicarbonate.
• Reassess kidney function within 24-48 hours after significant fluid administration.
• Avoid excessive fluid administration as patients with reduced kidney function have impaired ability to excrete excess volume, which could lead to fluid overload, pulmonary edema, or worsening kidney function 1.
• If the patient requires ongoing fluid therapy, consider nephrology consultation for guidance on fluid management strategy.

Monitoring and Management

Some key points to consider when managing fluid administration in patients with impaired renal function include:

• Careful evaluation of all physical findings, laboratory parameters, weight change, and net fluid change should be considered before discharge 1.
• Routine use of serial natriuretic peptide measurement or Swan-Ganz catheter has not been conclusively shown to improve outcomes among these patients 1.
• Theoretically, continuous diuretic infusion may enhance diuresis because continuous diuretic delivery to the nephron avoids rebound sodium and fluid reabsorption, but the DOSE trial did not find any significant difference between continuous infusion versus intermittent bolus strategies for symptoms, diuresis, or outcomes 1.

Recent Guidance

Recent guidance from 2022 suggests that careful monitoring for fluid overload is required when albumin is administered in patients with AKI because of the risk of pulmonary edema 1. This highlights the importance of careful fluid management in patients with renal impairment.

From the FDA Drug Label

This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. The FDA drug label does not answer the question.

From the Research

Fluid Administration in Patients with Impaired Renal Function

• The administration of fluids to patients with impaired renal function, specifically an estimated Glomerular Filtration Rate (eGFR) of 38, requires careful consideration of the type and volume of fluid to be used.
• According to a study published in 2015 2, the use of a buffered crystalloid compared with saline did not reduce the risk of acute kidney injury (AKI) among patients in the intensive care unit (ICU).
• Another study published in 2019 3 suggests that balanced crystalloids are pragmatic initial resuscitation fluids and improve patient outcomes compared to saline (0.9% sodium chloride).
• A study published in 2013 4 found that the use of hydroxyethyl starch (HES) for fluid resuscitation in ICU patients did not reduce 90-day mortality, but was associated with a higher rate of renal replacement therapy.
• A study published in 2019 5 compared the efficacy and safety of 20% albumin fluid loading with other resuscitation fluids in healthy subjects and found that 20% albumin was both effective and safe.
• A study published in 2015 6 found that adherence with dosing guidelines in patients with impaired renal function at hospital discharge was low, and that reporting the eGFR can improve adherence with dosing guidelines.

Considerations for Fluid Administration

• The choice of fluid should be based on individual patient factors, disease states, and other treatment remedies 3.
• The volume and rate of fluid administration should be carefully monitored to avoid overloading the patient and exacerbating renal impairment.
• The use of balanced crystalloids and albumin may be preferred over saline and HES due to their potential benefits in improving patient outcomes and reducing the risk of AKI 2, 3, 5.
• Regular monitoring of renal function and adjustment of fluid administration accordingly is crucial to prevent further renal impairment 6.