Neyra Javier A, Ortiz-Soriano Victor M, Ali Dina, Morris Peter E, Johnston Clayton M
Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.
Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA.
Kidney Int Rep. 2018 Sep 13;4(1):59-66. doi: 10.1016/j.ekir.2018.09.001. eCollection 2019 Jan.
Hyponatremia is a common electrolyte disorder in critically ill patients. Rapid correction of chronic hyponatremia may lead to osmotic demyelination syndrome. Management of severe hyponatremia in patients with acute or chronic kidney disease who require continuous renal replacement therapy (CRRT) is limited by the lack of commercially available hypotonic dialysate or replacement fluid solutions.
This was a single-center quality improvement project that consisted of the development and implementation of a multidisciplinary protocol for gradual correction of severe hyponatremia in patients who were admitted to the intensive care unit (ICU) and required CRRT. The protocol utilized a simplified method based on single-pool urea kinetic modeling and a hybrid technique of volume exchange, and addition of sterile water for sodium dilution of commercially available dialysate and replacement fluid solutions.
We report data of the first 3 ICU patients who required CRRT for acute kidney injury management, had severe hyponatremia (serum sodium <120 mEq/l), and were treated under the protocol. Targeted and gradual hyponatremia correction was achieved in all 3 patients. The observed versus the predicted serum sodium correction in each patient was concordant. No complications related to the protocol were reported. We detailed facilitators of and hindrances to the development and successful implementation of our multidisciplinary protocol.
We demonstrated gradual and individualized rates of severe hyponatremia correction utilizing customized (sodium dilution) dialysate/replacement fluid solutions in ICU patients who required CRRT. It is not known whether the use of customized solutions to prevent hyponatremia overcorrection has a significant impact on patient outcomes. Further research in this susceptible population is needed.
低钠血症是危重症患者常见的电解质紊乱。慢性低钠血症的快速纠正可能导致渗透性脱髓鞘综合征。对于需要持续肾脏替代治疗（CRRT）的急性或慢性肾脏病患者，严重低钠血症的管理因缺乏市售的低渗透析液或置换液而受到限制。
这是一项单中心质量改进项目，包括制定和实施多学科方案，用于逐步纠正入住重症监护病房（ICU）且需要CRRT的患者的严重低钠血症。该方案采用基于单池尿素动力学模型的简化方法以及容量交换的混合技术，并添加无菌水以稀释市售透析液和置换液中的钠。
我们报告了首批3例因急性肾损伤管理而需要CRRT、患有严重低钠血症（血清钠<120 mEq/L）且按照该方案接受治疗的ICU患者的数据。所有3例患者均实现了有针对性的低钠血症逐步纠正。每位患者观察到的与预测的血清钠纠正情况一致。未报告与该方案相关的并发症。我们详细阐述了多学科方案制定和成功实施的促进因素和障碍。
我们证明了在需要CRRT的ICU患者中，使用定制（钠稀释）透析液/置换液可实现严重低钠血症的逐步个体化纠正。使用定制溶液预防低钠血症过度纠正是否对患者结局有显著影响尚不清楚。对此易感人群需要进一步研究。
