This document summarizes guidelines for acute kidney injury management through volume replacement. It discusses various intravenous fluid options for volume expansion including crystalloids, sodium bicarbonate, synthetic colloids, and human albumin solutions. It also covers approaches for assessing fluid status and volume overload. The presentation provides an overview of the current evidence and recommendations regarding optimal volume replacement strategies for AKI.
14. Crit Care Med. 2011 Feb;39(2):386-91
17 RCT, n=1977
Outcome: Deaths
p .047
15. Crit Care Med. 2013; 41: 580–637.
And this is what KDIGO missing
16. BMJ. 2006 Nov 18;333(7577):1044.
n = 6045 Albumin Saline
17. J Chin Med Assoc. 2009 May;72(5):243-50
Albumin ≤ 20 g/L Albumin > 20 g/L
A daily minimum of 25 g intravenous human albumin for
3 days during their first 7 days of admission
18. Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for
expansion of intravascular volume in patients at risk
for AKI or with AKI.
• Albumin in severe sepsis and septic shock when
patients require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may
have a role in low serum albumin patient (<2-2.5
g/dl).
30. Sodium bicarbonate administration in the setting of lactic
acidosis has consistently failed to significantly improve
hemodynamic status in humans
July 16, 2019
05
31. In the bicarbonate group the following increased:
All-cause mortality
Risk of hypocalcaemia
04
35. NephSAP Volume 18, Number 2, May 2019 QUESTIONS
ICU patients with a pH less than 7.20, PaCO2 ≤45
mmHg, and serum bicarbonate ≤20 mmol/L
received 4.2% sodium bicarbonate (The bicarbonate
infusion was titrated to increase the arterial pH to
7.30):
• decreased rate of acute kidney injury requiring
renal replacement therapy
• improved mortality at 28 days
• lower rate of hyperkalemia,
• higher incidence of metabolic alkalosis,
hypernatremia, and hypocalcemia
36. Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
40. Talk Outline
• Crystalloids / Balanced crystalloids
• Hypotonic crystalloids
• Sodium bicarbonate
• Synthetic colloids
• Human albumin solutions
• How much fluid / Volume assessment
41. Albumin use
AKI in critically ill and septic patients
• Isotonic crystalloids for initial management for
expansion of intravascular volume in patients at risk
for AKI or with AKI.
• Albumin in severe sepsis and septic shock when
patients require substantial amounts of crystalloids.
• Albumin as a part of initial volume replacement may
have a role in low serum albumin patient (<2-2.5
g/dl).
55. Nephrotic Edema
Underfill vs. Overfill
Front Pediatr. 2016 Jan 11;3:111
Distinction between these mechanisms prior to
the initiation of diuretic therapy is not made in
routine clinical practice
Distinction has no effect on therapy strategy
selection in routine clinical practice
09
56. Albumin use
Diuretic Resistance - Hypoalbuminemia
Suggestion
Albumin should be reserved for patients with
resistant edema or ascites with sever
hypoalbuminemia (plasma albumin <2.0 g/dL) whom
diuretic doses have been maximized with no response
Ann Pharmacother. 2003 May;37(5):695-700.
Individualization
09
57. Albumin use - Precautions
Administration of albumin prior to furosemide
could potentiate greater increases in diuresis (than
administering both at the same time)
Albumin exert maximal effect of intravascular
volume expansion within 30 to 60 min of
administration
Sci. 2001, 16, 448–454.
08
58. Which type of albumin?
Salt-poor albumin !!
J Am Soc Nephrol. 2001;12(5):1010.
BMC Nephrol. 2012 Jan;13:92.
08
67. multiple vertical B-lines (arrows)
arising from the pleural line
2017 Jul;14(7):427-440
3 or more B lines in 2 or more
bilateral lung zones were
diagnostic for pulmonary edema
(sensitivity, 94%; specificity, 92%)
B-line score cutoff of 15 is
significantly correlated with
clinical congestion scores
Lung ultrasonography
Sodium bicarbonate produces CO2 after buffering plasma protons. This CO2 is then free to diffuse across cell membranes resulting in an intracellular hypercarbic acidemia, while bicarbonate is unable to cross cell membranes to buffer this effect.
Nonbicarbonate Buffers. Bicarbonate buffering results in carbon dioxide production and a lowering of free proton concentration. Lower free protons favors disassociation of nonbicarbonate buffers which, in turn, are buffered again by bicarbonate resulting in increasing carbon dioxide production resulting in a cycle of increasing intracellular carbon dioxide so long as exogenous bicarbonate is administered.
Acceleration of lactate generation — Acidemia may act as a "brake" on lactic acid generation by inhibiting glycolysis, largely mediated by a reduction in the activity of the enzyme, phosphofructokinase [17].