Crystalloid Fluid Replacement in Stage 5 Kidney Disease (ESRD)
Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) rather than 0.9% saline as the first-line fluid for patients with stage 5 kidney disease requiring intravenous fluid resuscitation. 1
Primary Fluid Choice
Balanced crystalloids should be the preferred initial fluid for volume expansion in ESRD patients, as they reduce the risk of hyperchloremic metabolic acidosis, acute kidney injury progression, and adverse renal events compared to normal saline 1, 2
Lactated Ringer's (containing 4 mmol/L potassium, osmolarity 277 mOsmol/L) or Plasma-Lyte (containing 5 mmol/L potassium, osmolarity 295 mOsmol/L) are both appropriate choices 3
The KDIGO guidelines specifically recommend isotonic crystalloids rather than colloids for intravascular volume expansion in patients at risk for or with acute kidney injury 1
Why Avoid Normal Saline
0.9% saline contains 154 mmol/L chloride, which causes hyperchloremic metabolic acidosis, renal vasoconstriction, and worsens kidney function 4, 5
The SMART trial demonstrated that balanced crystalloids reduced major adverse kidney events (death, new renal replacement therapy, or persistent creatinine elevation ≥200% baseline) compared to saline, with 14.3% vs 15.4% incidence respectively (P=0.04) 2
In critically ill patients, balanced crystalloids showed lower 30-day mortality (10.3% vs 11.1%) and reduced need for new renal replacement therapy (2.5% vs 2.9%) compared to saline 2
Addressing the Potassium Concern
The historical fear of potassium-containing fluids in ESRD patients is not evidence-based. 3
Randomized studies demonstrate that potassium levels actually increase more with 0.9% saline than with lactated Ringer's, even in renal transplant recipients 3
The physiologic principle: you cannot create hyperkalemia using a fluid with potassium concentration (4-5 mmol/L) lower than the patient's serum level 3
The only contraindication to balanced crystalloids is severe hyperkalemia (K+ >6.5 mmol/L with ECG changes), in which case temporarily use 0.9% saline until potassium is rechecked 3
Colloids: Not Recommended
Avoid hydroxyethyl starches in ESRD patients, as they increase acute kidney injury risk and need for renal replacement therapy 1, 3
The 6S Trial showed more deaths, more renal replacement therapy, and more severe bleeding with HES 130/0.42 compared to Ringer's acetate in critically ill patients 1
Albumin is not recommended as routine first-line therapy in ESRD patients requiring fluid resuscitation 1, 3
The SAFE, ALBIOS, and EARSS trials showed no mortality benefit of albumin over crystalloids, though albumin required lower total fluid volumes 1, 3
Gelatins should be avoided due to increased renal failure risk and lack of superiority over crystalloids 3
Volume Management Strategy
In ESRD patients with established kidney injury who are unresponsive to fluid administration, fluid restriction becomes the treatment of choice 6
Monitor for volume overload carefully, as both hypovolemia and fluid overload increase morbidity and mortality in critically ill patients with kidney disease 6
Use dynamic preload indexes (stroke volume variation, pulse pressure variation, passive leg-raising test) rather than static measurements (CVP) to assess fluid responsiveness 6
Limit 0.9% saline to maximum 1-1.5 L if it must be used, to minimize adverse effects 4
Common Pitfalls to Avoid
Do not default to normal saline based on outdated concerns about potassium in balanced solutions—this increases acidosis, hyperkalemia risk, and kidney injury 3, 4
Do not use colloids for "better volume expansion" in ESRD patients—they increase renal injury risk without mortality benefit 1, 3
Do not give liberal fluid volumes without assessing fluid responsiveness—restrictive fluid therapy prevents complications seen with large-volume administration 7, 6
Do not use hypotonic solutions in ESRD patients, as they are contraindicated in cerebral edema risk 7
Special Clinical Situations
In sepsis or septic shock with ESRD, balanced crystalloids remain the preferred choice over 0.9% saline to reduce mortality and adverse renal events 1
In hemorrhagic shock with ESRD, balanced crystalloids should be used as first-line therapy rather than 0.9% saline 1
For ESRD patients on hemodialysis, coordinate fluid administration with dialysis schedules to avoid volume overload between sessions 1