Can a dialysis patient still receive intravenous (IV) fluids?

Administration of IV Fluids in Dialysis Patients

Yes, dialysis patients can receive IV fluids when clinically indicated, but careful monitoring and consideration of fluid status is essential to prevent volume overload. 1, 2

Appropriate Use of IV Fluids in Dialysis Patients

• IV fluids should be administered with caution in dialysis patients, with careful assessment of fluid status to avoid hypervolemia, especially in patients with oliguria 1
• The FDA label for albumin specifically states that it can be used in renal dialysis patients for the treatment of shock or hypotension, with the usual volume administered being about 100 mL, while taking particular care to avoid fluid overload 2
• Intravenous fluids should be started promptly in patients with multiple myeloma and renal disease to decrease renal tubular light chain concentration, with a goal urine output of 100-150 mL/h 1

Fluid Type Selection for Dialysis Patients

• Balanced crystalloid solutions are generally preferred over 0.9% NaCl for fluid resuscitation to reduce mortality and adverse renal events 1
• For sepsis or septic shock patients, balanced crystalloids are recommended over 0.9% NaCl to reduce mortality and occurrence of adverse renal events 1
• Colloid solutions (like hydroxyethyl starches) should generally be avoided due to reported risks of renal failure and hemostasis disorders 1

Special Considerations for Electrolyte Management

• Dialysis patients are prone to electrolyte disorders, particularly when receiving intensive kidney replacement therapy (KRT) 1
• Common laboratory abnormalities during intensive/prolonged KRT include hypophosphatemia, hypokalemia, and hypomagnesemia, which should be monitored when administering IV fluids 1
• Dialysis solutions containing potassium, phosphate, and magnesium should be used to prevent electrolyte disorders during KRT 1

Volume Management Approach

• Fluid volume management in hemodialysis patients is an essential component of dialysis adequacy and requires precise monitoring 3
• The traditional "dry weight" probing approach should be balanced against the risk of cardiovascular stress from aggressive fluid removal 3
• Assessment of fluid status should include clinical evaluation, non-invasive tools (ultrasound, bioimpedance), cardiac biomarkers, and sodium modeling 3

Clinical Algorithm for IV Fluid Administration in Dialysis Patients

1. Assess the indication for IV fluids:

   • Is the patient hypotensive or in shock? 2
   • Is there a specific clinical need (medication administration, contrast studies)? 1

2. Evaluate current fluid status:

   • Check for signs of fluid overload (edema, pulmonary congestion) 2, 3
   • Review recent weight changes and ultrafiltration requirements 3

3. Select appropriate fluid type:

   • For most situations requiring volume, use balanced crystalloids 1, 4
   • Consider albumin (25g) for shock or hypotension during dialysis 2
   • Avoid synthetic colloids due to renal risk 1

4. Determine appropriate volume and rate:

   • Use minimal effective volume (often 100mL for albumin in dialysis patients) 2
   • Consider the timing relative to the next dialysis session 3
   • Monitor response closely and adjust accordingly 1, 3

Common Pitfalls to Avoid

• Administering large volumes of fluid that will require additional ultrafiltration during subsequent dialysis sessions 2, 3
• Using 0.9% saline for large volume resuscitation, which can cause hyperchloremic metabolic acidosis 1, 4
• Failing to adjust dialysis prescription to account for additional fluid administered 3
• Overlooking the risk of electrolyte disturbances when administering IV fluids between dialysis sessions 1