Guidelines for Using Mannitol in Patients with Chronic Kidney Disease (CKD)
Mannitol should be administered with extreme caution in CKD patients and is contraindicated in patients with oligoanuria. 1
Contraindications and Cautions
- Mannitol is contraindicated in patients with well-established anuria due to severe renal disease 2
- Mannitol should be administered carefully and is contraindicated in patients with oligoanuria 1
- Patients with pre-existing renal disease are at increased risk of renal failure with administration of mannitol 2
- Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol in CKD patients 2
Specific Clinical Scenarios
Rhabdomyolysis in CKD
- Mannitol administration may be of benefit only in patients with marked elevations in creatinine kinase level (>30,000 U/L), but even in these patients with severe rhabdomyolysis, the true benefit remains undefined 1
Contrast-Induced Nephropathy
- Mannitol is detrimental for contrast-induced nephropathy prevention and may negatively affect serum creatinine levels in patients undergoing injection of radiocontrast agents 3
Renal Transplantation
- Mannitol may reduce the incidence of acute renal failure or need for dialysis in recipients of renal transplantation (NNT 3.03) 3
Vascular Surgery
- Mannitol may provide renal protection in CKD patients undergoing suprarenal aortic clamping during open aneurysm repair 4
Monitoring and Risk Assessment
- Evaluate the renal, cardiac, and pulmonary status of the patient and correct fluid and electrolyte imbalances prior to administration of mannitol 2
- Discontinue mannitol if renal, cardiac, or pulmonary status worsens 2
- Mannitol administration may obscure and intensify inadequate hydration or hypovolemia 2
- Excessive loss of water and electrolytes may lead to serious imbalances, including hypernatremia and hyponatremia 2
- Monitoring of cardiovascular status and electrolyte levels is recommended during mannitol therapy 2
Dosing Considerations
- The FDA-approved dosage for mannitol depends on the indication, with typical doses ranging from 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes 2
- For small or debilitated patients, a reduced dose of 500 mg/kg is recommended 2
- In patients with renal impairment, dose adjustment may be necessary based on the patient's renal function 2
Alternative Approaches
- There are no pharmacotherapies available for the prevention or treatment of acute kidney injury in adults, so recommendations to avoid these are reasonable 1
- For volume overload in AKI, diuretics may be used, but there is no evidence supporting the use of diuretics to prevent AKI 1
Clinical Pitfalls to Avoid
- Mannitol should not be added to whole blood for transfusion 2
- Accumulation of mannitol may intensify existing or latent congestive heart failure 2
- Mannitol may increase cerebral blood flow and the risk of postoperative bleeding in neurosurgical patients 2
- Recent evidence suggests that mannitol administration failed to provide added value on renal functional preservation after partial nephrectomy in CKD patients 5