Therapeutic hypernatremia management during continuous renal replacement therapy with elevated intracranial pressures and respiratory failure

  • Tibor FülöpEmail author
  • Lajos Zsom
  • Rafael D. Rodríguez
  • Jorge O. Chabrier-Rosello
  • Mehrdad Hamrahian
  • Christian A. KochEmail author


Cerebral edema and elevated intracranial pressure (ICP) are common complications of acute brain injury. Hypertonic solutions are routinely used in acute brain injury as effective osmotic agents to lower ICP by increasing the extracellular fluid tonicity. Acute kidney injury in a patient with traumatic brain injury and elevated ICP requiring renal replacement therapy represents a significant therapeutic challenge due to an increased risk of cerebral edema associated with intermittent conventional hemodialysis. Therefore, continuous renal replacement therapy (CRRT) has emerged as the preferred modality of therapy in this patient population. We present our current treatment approach, with demonstrative case vignette illustrations, utilizing hypertonic saline protocols (3% sodium-chloride or, with coexisting severe combined metabolic and respiratory acidosis, with 4.2% sodium-bicarbonate) in conjunction with the CRRT platform, to induce controlled hypernatremia of approximately 155 mEq/L in hemodynamically unstable patients with acute kidney injury and elevated ICP due to acute brain injury. Rationale, mechanism of activation, benefits and potential pitfalls of the therapy are reviewed. The impact of hypertonic citrate solution during regional citrate anticoagulation is specifically discussed. Maintaining plasma hypertonicity in the setting of increased ICP and acute kidney injury could prevent the worsening of ICP during renal replacement therapy by minimizing the osmotic gradient across the blood-brain barrier and maximizing cardiovascular stability.


Acute kidney injury Blood-brain barrier Hypernatremia Brain injury Intracranial pressure Continuous renal replacement therapy Neurosurgery Regional citrate anticoagulation Rhabdomyolysis Serum osmolality Volume overload 



acute brain injury


acute kidney injury


blood urea nitrogen


continuous renal replacement therapy


intracranial pressure


intensive care unit




Renal replacement therapy


Continuous renal replacement therapy



Parts of this projects has been presented in poster format at the 2018 Annual Dialysis Conference, March 3-6, 2018, Orlando, FL and at the 14th International Conference on Continuous Renal Replacement Therapies, Feb 25-28, 2009, San Diego, CA (Blood Purif 2009; 27:271-305). Case vignette #1 was observed at the University of Mississippi Medical Center, while Drs. Fülöp, Koch, and Zsom were serving on the faculty of the Department of Medicine. Drs. Rafael D. Rodríguez and Jorge O. Chabrier-Rosello are current Nephrology trainee at the Department of Medicine, Medical University of South Carolina, SC (Class of 2019).

We sincerely appreciated the assistance of Mr. Attila Lénárt-Muszka during editing and grammar review.

Compliance with ethical standards

Conflict of interest

Dr. Zsom is a current employee of Fresenius Medical Care (FMC) Hungary and Dr. Fülöp is a former employee of FMC Hungary. Dr. Fülöp is a current employee of the United States Veterans Health Administration. However, the views and opinions expressed herewith do not reflect the official views or opinion or endorsed by the FMC Hungary or the United States Veteran Health Administrations. None of the other authors declares a conflict of interest with this article.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Tibor Fülöp
    • 1
    • 2
    Email author
  • Lajos Zsom
    • 3
  • Rafael D. Rodríguez
    • 1
  • Jorge O. Chabrier-Rosello
    • 1
  • Mehrdad Hamrahian
    • 4
  • Christian A. Koch
    • 5
    • 6
    • 7
    • 8
    Email author
  1. 1.Department of Medicine - Division of NephrologyMedical University of South CarolinaCharlestonUSA
  2. 2.Medical ServicesRalph H. Johnson VA Medical CenterCharlestonUSA
  3. 3.Fresenius Medical Care Hungary KftCeglédHungary
  4. 4.Department of Medicine – Division of NephrologyThomas Jefferson UniversityPhiladelphiaUSA
  5. 5.Medicover GmbHBerlinGermany
  6. 6.Carl von Ossietzky University of OldenburgOldenburgGermany
  7. 7.Technical University of DresdenDresdenGermany
  8. 8.University of Tennessee Health Science CenterMemphisUSA

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