Impact of protocolized fluid management on electrolyte stability in patients undergoing continuous renal replacement therapy

Song In Baeg; Junseok Jeon; Danbee Kang; Soo Jin Na; Juhee Cho; Kyunga Kim; Jeong Hoon Yang; Chi Ryang Chung; Jung Eun Lee; Wooseong Huh; Gee Young Suh; Yoon-Goo Kim; Dae Joong Kim; Hye Ryoun Jang

doi:10.3389/fmed.2022.915072

Impact of protocolized fluid management on electrolyte stability in patients undergoing continuous renal replacement therapy

Front Med (Lausanne). 2022 Aug 31:9:915072. doi: 10.3389/fmed.2022.915072. eCollection 2022.

Authors

Song In Baeg^{1

2}, Junseok Jeon², Danbee Kang^{3

4}, Soo Jin Na⁵, Juhee Cho^{3

4}, Kyunga Kim⁶, Jeong Hoon Yang⁵, Chi Ryang Chung⁵, Jung Eun Lee², Wooseong Huh², Gee Young Suh⁵, Yoon-Goo Kim², Dae Joong Kim², Hye Ryoun Jang²

Affiliations

¹ Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, South Korea.
² Division of Nephrology, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, South Korea.
³ Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea.
⁴ Center of Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea.
⁵ Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
⁶ Statistics and Data Center, Samsung Medical Center, Seoul, South Korea.

Abstract

Objective: Continuous renal replacement therapy (CRRT) is the standard treatment for critically ill patients with acute kidney injury (AKI). Electrolyte disturbance such as hypokalemia or hypophosphatemia occurs paradoxically in patients undergoing CRRT due to high clearance. We developed a fluid management protocol for dialysate and replacement fluid that depends on serum electrolytes and focuses on potassium and phosphate levels to prevent electrolyte disturbance during CRRT. The impact of our new fluid protocol on electrolyte stability was evaluated.

Methods: Adult patients who received CRRT between 2013 and 2017 were included. Patients treated 2 years before (2013-2014; pre-protocol group) and 2 years following development of the fluid protocol (2016-2017; protocol group) were compared. The primary outcomes were individual coefficient of variation (CV) and abnormal event rates of serum phosphate and potassium. Secondary outcomes were frequency of electrolyte replacement and incidence of cardiac arrhythmias. Individual CV and abnormal event rates for each electrolyte were analyzed using the Wilcoxon rank-sum test and Chi-square test with Yates' continuity correction.

Results: A total of 1,448 patients was included. Both serum phosphate and potassium were higher in the protocol group. The CVs of serum phosphate (pre-protocol vs. protocol, 0.275 [0.207-0.358] vs. 0.229 [0.169-0.304], p < 0.01) and potassium (0.104 [0.081-0.135] vs. 0.085 [0.064-0.110], p < 0.01) were significantly lower in the protocol group. The abnormal event rates of serum phosphate (rate [95% CI], 0.410 [0.400-0.415] vs. 0.280 [0.273-0.286], p < 0.01) and potassium (0.205 [0.199-0.211] vs. 0.083 [0.079-0.087], p < 0.01) were also significantly lower in the protocol group.

Conclusion: The protocolized management of fluid in CRRT effectively prevented hypophosphatemia and hypokalemia by inducing excellent stability of serum phosphate and potassium levels.

Keywords: acute kidney injury; continuous renal replacement therapy; critically ill patient; electrolyte imbalance; fluid.