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Kidney Week

Abstract: PO0101

Novel Prescription of Continuous Venovenous Hemodialysis Dialysate Na+ in a Patient with Cerebral Edema and Severe Hypernatremia

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Young, Brian Y., University of California at Davis, Division of Nephrology, Department of Internal Medicine, Sacramento, California, United States
  • Wiegley, Nasim, University of California at Davis, Division of Nephrology, Department of Internal Medicine, Sacramento, California, United States
  • Howard, John, University of California at Davis, Division of Nephrology, Department of Internal Medicine, Sacramento, California, United States
Introduction

AKI necessitating dialysis is difficult in patients with traumatic brain injury. Slow clearance and increased dialysate Na+ are recommended. Yet, barriers in adjusting dialysate Na+ may occur with premixed commercial dialysate. We present a unique method of prescribing CVVHD to prevent Na+ overcorrection in a patient with cerebral edema and severe hypernatremia.

Case Description

An 18 year old male presented with polytrauma after a motor vehicle accident. His injuries included multiple intracranial bleeds. On day 13, nephrology was consulted for AKI, BUN > 150 mg/dl, and refractory hyperkalemia. Head CT scan showed known bleeds and diffuse cerebral edema. At consult, IV 3% saline had already resulted in plasma Na+ ranging 161-166 meq/L for > 3 days.

Our hospital performs CVVHD via NxStage with commercial dialysate bags with Na+ fixed at 140 meq/L. To avoid Na+ overcorrection, we combined commercial bags and 3% saline in-circuit. Initially, clearance goals were set by dialysate flow rate. Then, separate IV pump for 3% saline was Y connected to the pre-pump dialysate line, and IV pump rate was calculated to adjust final dialysate Na+ (Figure). Final dialysate flow equated to IV pump flow plus residual drawn from commercial bags. Our initial goal dialysate Na+ was 160 meq/L. Dialysis solution labs steadily showed adjusted dialysate Na+ of about 158+ meq/L at initiation. Changes to other dialysate factors (i.e. K+, HCO3-) were negligible. CVVHD was started with titration of the dialysis-attached 3% saline IV pump to control of dialysate Na+. All other 3% saline was discontinued. Though the patient ultimately died from overall injuries, change in plasma Na+ was slow and controlled (10 meq in 7 days).

Discussion

We present a new method for adjusting dialysate Na+ using in-circuit mixing of commercial dialysate and 3% saline. Our method used readily available solutions, was easy to titrate, depended solely on dialysis, and did not require manipulation of commercial bags. We suggest consideration of our method in CVVHD, brain trauma, and hypernatremia.